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Regional  Anesthesia 

(VICTOR  PAUCHET'S  TECHNIQUE) 


:by 


B.  SHERWOOD-DUNN,   M.D. 

Officier  d'Academie  ;   Surgeon   (Colonel)    Service   de  Santk  Militaire   de 
Paris;   Physician  to  the  Cochin  Hospital. 


WITH  224  FIGURES  IN   THE    TEXT 


PHILADELPHIA 
F.  A.  DAVIS  COMPANY,  Publishers 

English  Depot 
Stanley  Phillips,  London 

1920 


COPYRIGHT,   1920 

by' 

F.   A.    DAVIS   COMPANY 

Copyright,  Great  Britain.     All  Rights  Reserved, 


PRESS   OF 

F.    A.     DAVIS     COMPANY 

PHILADELPHIA.    U.S.A. 


PREFACE. 


For  thirty  years  Professor  Reclus,  of  the 
Paris  Facuhe,  preached  and  practised  local  anes- 
thesia. His  method  consisted  in  infiltrating  the 
tissues  upon  which  he  proposed  to  operate  with  a 
weak  solution  of  cocaine — then  proceeding  with 
the  operation. 

This  procedure  is  well  known  in  France,  and 
is   often  employed  in  minor   operations. 

Regional  anesthesia  differs  widely  from  the 
method  of  Reclus.  Instead  of  applying  the  anes- 
thetic to  the  terminals  of  the  nerves,  it  is  injected 
at  the  point  of  the  origin  of  the  nerve,  or  along 
the  trunk  near  the  point  of  origin,  so  that  the 
whole  region  supplied  by  the  nerve  and  its  branches  is 
anesthetized.^  All  the  major  as  well  as  the  most  deli- 
cate minor  operations  can  be  performed  in  this  way. 
The  method  has  gained  many  adherents  since 
1914,  and  its  growing  popularity  has  led  us  to 
believe  that  an  exposition  of  it  would  be  wel- 
comed  by   the   American   profession. 

Professor  Victor  Pauchet  is  acknowledged  to 
be  the  leading  exponent  of  regional  anesthesia  in 
France,  and  this  book  constitutes  a  resume  of  his 

(iii) 


IV 


PREFACE. 


writings  upon  this  subject,  together  with  those  of 
P.  Sourdat  and  J.  Laboure.  In  addition  there  is 
included  the  latest  experiences  of  Pauchet  and  the 
writer,  together  with  Pauchet's  recommendations, 
inserted  during  his  revision  and  amplification  of 
the  manuscript  before  its  transmission  to  the  pub- 
lishers. 

I  wish  to  acknowledge  my  indebtedness  to  Dr. 
Emilie  Jane  and  Miss  Frances  Johnson,  R.  N., 
and  to  express  my  high  appreciation  of  the  assist- 
ance which  they  have  rendered  me  in  the  prepara- 
tion  of   this   work   for   publication. 

B.   Sherwood-Dunn. 


CONTENTS. 


CHAPTER  I. 

PAGE 

General  Considerations  1 

Advantages  of  Regional  Anesthesia 1 

Disadvantages  of  Regional  Anesthesia 5 

CHAPTER  n. 

Armamentarium  12 

Syringes 12 

Needles    12 

Anesthetic  14 

General  Technique  17 

CHAPTER  HI. 

Cranial  Operations Zl 

Treatment  of  Large  Wounds  in  the  Soft  Tissues,  or  of  Com- 
pound Fractures  of  the  Skull  40 

Removal  of  Malignant  Tumors   of  the   Cranium,   vi^ith   Bone 

Resection  42 

Trephining  the  Temporal  Region  43 

Exposure  of  the  Cerebellum   46 

CHAPTER  IV. 

Anesthesia  of  the  Head  and  Neck 48 

Anesthesia  of  the  Gasserian  Ganglion    48 

Anesthesia  of  the  Trigeminal  Nerve  Distribution  57 

Regional  Anesthesia  in  Rhinology   80 

Regional  Anesthesia  in  Otology  85 

Regional  Anesthesia  in  Ophthalmology  91 

Regional  Anesthesia  in  Dental  Surgery   94 

Regional  Anesthesia  of  the  Face  and  Javi^s  97 

Regional  Anesthesia  of  the  Tongue,  Floor  of  the  Mouth,  Ton- 
sils and  Palate 105 

Regional  Anesthesia  in  Operations  of  the  Neck  109 

(v) 


vi  CONTENTS. 

CHAPTER  V. 

PAGE 

Anesthesia  of  the  Thorax  and  Abdomen 128 

Intraspinal  Anesthesia   128 

Nerve-trunk  Anesthesia  136 

Paravertebral  Anesthesia    144 

Paracentesis  of  the  Pleural  Cavity  153 

Thoracotomy  for  Empyema  with  Costal  Resection   153 

Resection   of  the  Second  to   the  Fifth   Costal   Cartilages    for 

Rigidity  of  the  Thorax   155 

Operations  upon  the  Sternum  158 

Thoracotomy  for  Abscess  of  the  Lung,  etc 158 

Operations  for  Tumor  of  the  Breast 160 

Operations   in  the  Axilla    162 

Abdomen 162 

Operations  upon  the  Stomach   165 

Median   Hypogastric   Incision    167 

Operations  in  the  Iliac  Fossa 169 

Umbilical  Hernia   186 

Inguinal  Hernia 188 

Femoral  Hernia   195 

Operations  upon  the  Kidneys  198 

Operations  upon  the  Biliary  Passages   199 

CHAPTER  VI. 

Anesthesia  of  the  Genito-urinary  Organs  and  Rectum  200 

Anterior  Sacral  Anesthesia   (Pre-sacral)    205 

Anesthesia   through    the    Sacral    Foramina — Trans-sacral    An- 
esthesia     207 

Operations  upon  the  Bladder    212 

Operations  upon  the  Testicles  and  Scrotum  214 

Operations  upon  the  Penis    217 

Operations  upon  the   Posterior   Urethra 219 

Operations  upon  the   Prostate    220 

Operations  upon  the  Vulva  and  Vagina  220 

Operations  upon  the  Anus 224 

CHAPTER  VII. 

PAGE 

Anesthesia  of  the  Extremities  230 

Upper  Extremity    232 

Operations  upon  the  Hand 245 

Operations  upon  the  Forearm  258 


CONTENTS.  vii 

Anesthesia  of  the  Extremities   (continued) . 

Upper  Extremity,  Operations  at  the  Elbow    261 

Operations  upon  the  Arm  263 

Operations  upon  the  Shoulder   264 

Lower  Extremity   265 

Operations  upon  the  Toes  270 

Operations  upon  the  Entire  Foot  272 

Operations  upon  the  Knee  274 

Operations  upon  the  Soft  Part  of  the  Thigh   277 

Conclusions 283 

Index    285 


CHAPTER    I. 

GENERAL   CONSIDERATIONS. 
Advantages   of   Regional   Anesthesia. 

Anesthesia  by  injection  possesses,  as  compared 
with  anesthesia  by  general  narcosis,  advantages  of 
such  cardinal  importance  that,  at  the  very  outset, 
the  reader's  attention  should  be  directed  to  them 
as  ample  justification  for  the  time,  labor  and 
special  education  required  to  become  sufficiently 
expert  in  its  application  to  permit  of  its  adoption 
for   general  employment. 

Lozv  Mortality  Risks. — Since  the  concentrated 
solutions  of  cocaine  have  been  replaced  by  weak 
solutions  of  the  less  toxic  agents,  such  as  sto- 
vaine,  novocaine,  procaine,  etc.,  death  from  local 
or  regional  anesthesia  has  disappeared  from  sur- 
gical practice.  The  writer  is  unaccj[uainted  with 
a  single  case  of  death  due  to  the  employment  of 
the   last  named   anesthetics. 

The  relative  rarity  of  death  from  narcosis 
(chloroform,  i  in  2000;  ether,  i  in  5000)  may 
make  this  advantage  seem  insignificant;  but  it  is 
only  necessary  for  an  operator  to  lose  one  patient 
by  narcosis,  to  have  this  apparently  insignificant 
advantage    brought    forcibly    to    his    attention. 

(1) 


2  REGIONAL   ANESTHESIA. 

Reduction  of  Post-operative  Dangers. — General 
narcosis,  aside  from  its  mortality,  produces  com- 
plications which  are  of  great  importance  because 
of  their  frequent  occurrence.  They  include  chiefly  pul- 
monary complications,  caused  or  aggravated  by 
etherization,  and  alterations  in  the  liver  and  kid- 
neys through  the  action  of  ether,  and  particularly 
of  chloroform.  Rapid  degeneration  of  the  liver 
and  kidneys  following  surgical  operations  is  often 
attributed  to  shock  or  post-operative  infection,  but 
the  fact  that  these  accidents  are  eliminated  by 
regional  anesthesia  would  indicate  that  they  are 
directly  due  to  the  action  of  the  compounds  used 
in  general  narcosis,  and  the  superiority  of  regional 
anesthesia  is  made  strikingly  apparent  in  opera- 
tions upon  subjects  suffering  with  chronic  jaun- 
dice or  renal  insufficiency.  The  nausea  and  vomit- 
ing, which  often  continue  for  forty-eight  hours 
after  an  operation  and  are  such  prominent  factors 
in  reducing  the  vital  forces — especially  in  patients 
with  strength  already  at  the  lowest  ebb — are  often 
the  determining  cause  of  death.  These  trouble- 
some conditions  are  eliminated  in  regional  anesthesia. 

Dimmntion  of  Shock. — The  reflex  action  of 
traumatism,  the  unconscious  suffering  of  a  patient 
even  under  the  full  influence  of  narcosis,  is  trans- 
mitted to  the  nerve  centers,  provoking  disturbances 
which,  repeated,  result  in  certain  alterations  in  the 
neurons,   and   these   alterations  constitute    shock. 

Local  or  regional  anesthesia  secures  a  com- 
plete physiological   section  of  the  nerves  and   sup- 


GENERAL   CONSIDERATIONS.  3 

presses    completely    this    influence    upon    the    nerve 
centers. 

This  fact  has  been  so  fully  demonstrated  that 
Crile  (of  Cleveland)  practises  local  and  regional 
anesthesia  in  all  of  his  major  operations,  even 
when  employing  general  narcosis  with  nitrous 
oxide.  If  comparison  is  made  between  a  series 
of  operations  for  cancer  of  the  stomach  under 
narcosis  and  a  series  under  regional  anesthesia, 
the  relative  condition  of  the  patients  subsequently 
offers  a  striking  confirmation  of  the  innocuousness 
of  the  latter  procedure. 

Absence  of  Danger  front  Asphyxia. — Adminis- 
tration of  ether  or  chloroform  is  generally  at- 
tended by  greater  or  less  respiratory  disturbances. 
Onlookers  often  have  their  attention  attracted  by 
the  patient's  difficulty  in  breathing,  due  generally 
to  mucus  collecting  in  the  mouth  and  nose,  espe- 
cially in  the  Trendelenburg  position.  Not  infre- 
quently the  operator's  attention  is  arrested  by  the 
same  difficulty.  All  of  this  is  absent  in  injection 
anesthesia. 

Operations  upon  the  respiratory  tract,  or  in 
its  vicinity,  are  greatly  simplified  and  facilitated. 
The  patient  assumes  whatever  position  is  desired, 
being  perfectly  conscious.  He  can  at  will  arrest 
his  breathing,  suppress  a  cough,  or  expectorate  if 
need  be.  This  is  of  valuable  assistance  in  opera- 
tions upon  the  pleura,  larynx,  neck,  etc.  In  oper- 
ations for  goiter  it  safeguards  the  recurrent  laryn- 
geal nerve  by  allowing  the  patient  to  speak,  thus 
calling   attention   to   the    nerve. 


4  REGIONAL   ANESTHESIA. 

Special  Advantages  in  Certain  Operations. — 
The  fan-like  distribution  of  the  nerves  after  they 
leave  the  large  nerve  trunks  permits  the  per- 
formance of  extensive  operations  once  the  trunk 
has  been  anesthetized.  Thus  a  bronchial  tumor, 
or  the  cervical  glands  can  be  removed,  or  total 
laryngectomy  or  external  esophagotomy  performed 
after  preliminary  infiltration  of  the  cervical  plexus. 

Nephrectomy  can  be  painlessly  performed  after 
paravertebral  infiltration  of  six  intercostal  and 
two  lumbar  trunks;  not  only  are  the  parietes 
rendered  insensible,  but  the  kidney  can  be  sutured 
or  the  pedicle  liberated  and  ligated  without  pain. 
The  same  advantage  attaches  in  operations  upon 
the  liver  and  stomach.  The  rectum  can  be  excised 
after  injecting  through  the  sacral  foramen. 

Compared  with  the  method  of  local  infiltration, 
practised  by  Reclus,  regional  anesthesia  possesses 
the  following  advantages : 

(i)  The  anesthesia  is  entirely  distinct  from  the 
operation  proper,  being  instituted  beforehand,  and  if 
possible,  by  an  assistant  in  an  adjoining  room.  Con- 
sequently, successive  operations  can  be  performed 
without  loss  of  time, 

(2)  Once  the  nerve  or  nerves  have  been  properly 
anesthetized,  the  anesthesia  continues  complete  for 
from  one  and  one-half  to  tzvo  and  one-half  hours 
and  the  operation  is  never  interrupted  to  make  addi- 
tional injections  as  is  often  the  case  in  infiltration 
anesthesia. 

(3)  It  obviates  all  danger  of  necrosis  of  the  tis- 
sues, such  as  sometimes  occurs  in  local   infiltration 


GENERAL   CONSIDERATIONS.  5 

where  a  section  of  the  skin  is  mobiHzed  in  a  plastic 
operation  to  cover  a  denuded  surface  and  is  nour- 
ished only  by  a  narrow  pedicle. 

Disadvantages  of  Regional  Anesthesia. 

Special  Training  Required. — Some  training  in 
the  practical  method  of  application  is  required  to  per- 
mit of  successful  practice  of  this  procedure — though 
not  more  than  is  necessary  for  the  execution  of  any 
of  the  simpler  types  of  surgical  operations. 

As  the  simplest  and  most  rapid  procedure  for 
securing  the  necessary  experience  we  advise  that 
the  operator,  after  reading  the  detailed  descrip- 
tions herein  presented,  first  practise  finding  upon 
the  skeleton,  with  needles  of  varying  lengths,  the 
cranial,  spinal,  intercostal  and  sacral  nerve  for- 
amina. 

When  he  has  become  familiar  with  the  depths 
and  directions  of  the  various  punctures  through  ex- 
ercises upon  the  skeleton,  the  student  of  the  method 
may  then  repeat  the  various  operations  upon  the 
cadaver,  using  the  longer  and  coarser  needles  and  a 
fluid  containing  India  ink.  Dissection  of  the  more 
difficult  regions,  after  such  experimentation,  will 
disclose  any  faults  and  soon  draw  the  operator's  at- 
tention to  any  necessary  corrections.  Too  much  time 
need  not  be  spent  in  this  experimental  work,  how- 
ever, before  the  operator  begins  upon  the  living  sub- 
ject, as  no  harm  results  from  the  injection  of  the 
fluid.  But  little  actual  experience  is  required  for  the 
surgeon  to  become  confident  and  adept  in  finding  the 


6  REGIONAL   ANESTHESIA. 

nerve  trunks,  this  being  facilitated  by  the  more  or 
less  pronounced  sensation  referred  to  the  terminal 
distributions  when  the  point  of  the  needle  touches 
the  nerve  trunk,  or  by  the  insensibility  of  the  sur- 
faces supplied. 

It  will  assist  the  operator  in  rapidly  gaining  con- 
fidence and  skill  if  he  will  use  at  first  a  larger  amount 
and  a  stronger  solution  and  infiltrate  a  more  exten- 
sive area. 

Necessity  of  Gentleness  and  Skill  in  Operative 
Technique. — It  is  obvious  that  where  an  operation 
must  be  done  with  the  complete  consciousness  and 
oftentimes  in  full  view  of  the  patient,  a  gentle,  un- 
hurried, and  quiet  technique  is  imperative  and  is 
conducive  to  a  greater  degree  of  satisfaction  to 
the  patient,  with  better  results. 

Some  operators  are  accustomed  to  break  up  ad- 
hesions and  carry  out  many  surgical  maneuvers  with 
their  hands  and  fingers.  With  injection  anesthesia 
in  abdominal  operations  especially,  all  pulling,  tear- 
ing, and  rough  treatment  should  be  avoided,  as  even 
with  complete  insensibility  of  the  parts  the  patient 
cannot  but  be  cognizant  of  the  methods  employed, 
and  any  such  treatment  produces  an  unfavorable 
mental  impression  which  is  prejudicial  to  final  suc- 
cess. The  scalpel  and  scissors  should  be  used  for  all 
necessary  separation  of  parts.  Again,  it  is  the  habit 
of  some  to  employ  in  their  operations  a  variety  of 
retractors,  which  are  often  the  cause  of  unnecessary 
traumatism  to  the  parts.  This  may  also  be  said  of 
the  employment  of  an  unnecessary  number  of  pres- 
sure  and   rat-tooth   forceps. 


GENERAL   CONSIDERATIONS.  7 

It  must  not  be  overlooked  that  a  difference  exists 
between  sensation  and  pain;  unnecessary  pulling 
and  handling  of  parts  produces  a  disagreeable  sen- 
sation which  is  likely  to  cause  complaint  on  the  part 
of  the  patient. 

The  more  gently  and  quickly  the  operator  pro- 
ceeds, the  greater  will  be  his  measure  of  operative 
success. 

Objection  that  the  Method  Procures  only  a  Partial 
Anesthesia. — In  regional  anesthesia  it  has  been  our 
experience  that,  out  of  20  cases,  12  are  completely 
insensible;  7  are  sufficiently  insensible  to  all  neces- 
sary manipulations  to  permit  of  the  operative  pro- 
cedure without  serious  complaint  on  the  part  of  the 
patient;  while  i  case  out  of  20  is  found  insufficiently 
anesthetized  and  must  be  given  a  little  ethyl  chloride 
to  overcome  the  deficiency.  Even  in  this  event  the 
quantity  of  inhalation  anesthetic  required  is  very 
slight. 

The  value  of  regional  anesthesia  is  demonstrable 
by  comparison,  chiefly  with  general  narcosis.  The 
reader  need  only  be  reminded  of  the  distressing  ex- 
periences which  attend  the  beginning  and  the  close 
of  the  latter  procedure,  and  but  little  experience  with 
the  former  will  convince  any  expert  operator  of  its 
marked  superiority.  Apart  from  the  distressing 
period  of  vomiting  which  follows  general  narcosis, 
the  after  pains  complained  of  during  the  succeeding 
day  and  night  are  usually  greatly  diminished  in 
regional  anesthesia,  and  after  nephrectomy,  lapa- 
rotomy, and  facial  operations  a  lasting  condition  of 
hypoanesthesia  may  often  be  noted,   which  renders 


8  REGIONAL   ANESTHESIA. 

the  injection  of  morphine  or  other  narcotic  during 
the  succeeding  twenty-four  hours  unnecessary. 

True,  the  patient  will  often  complain  at  some 
time  or  other  during  the  course  of  the  operation. 
One  says  the  table  is  too  hard;  another  asks  if  the 
operation  will  not  soon  be  finished;  many  complain 
of  suffering  because  they  confound  sensation  wath 
pain.  One  of  our  patients  cried  out  when  he  heard 
a  fragment  of  his  rib  fall  into  the  slop  basin.  These 
are  minor  inconveniences  which  it  is  well  to  be  aware 
of  in  order  to  be  prepared  for  them  when  they  be- 
come manifest.  The  table  should  be  well  padded. 
In  nervous  and  sensitive  cases  it  is  advisable  to 
blindfold  the  patient's  eyes  and  to  stop  the  ears  with 
cotton. 

Before  all  operations  the  patient  should  be  given 
an  injection  of  scopolamine-morphine,  which  not 
only  does  not  interfere  with,  but  rather  assists  the 
method.  Absolute  silence  should  be  maintained  in 
the   operating   room. 

Necessarily  the  operator  must  have  become 
perfected  in  the  details  and  technique  of  the  regional 
form  of  anesthesia.  Any  operator  who,  in  the  anes- 
thetization of  his  patients,  has  had  to  rely  upon  the 
services  of  different  assistants,  knows  how  seldom 
a  good  one  is  found.  The  number  of  patients  who 
are  insufficiently  or  imperfectly  brought  under  the 
anesthetic  and  bear  down  or  resist  during  the  course 
of  the  operation  is  legion,  while  not  infrequently 
cases  absorb  too  much  of  the  anesthetic,  causing  the 
operator  to  discontinue  his  work  while  the  patient 
is  brought  back  from  the  danger  line.     It  is  not  too 


GENERAL   CONSIDERATIONS.  9 

much  to  ask,  therefore,  that  the  operator  intending 
to  make  use  of  regional  anesthesia  should  carefully 
and  completely  train  himself  in  the  details  of  the 
procedure  and  persevere  in  his  technical  practice 
until  he  has  reached  a  satisfactory  degree  of  perfec- 
tion, just  as  he  does  in  any  and  every  other  depart- 
ment of  medical  practice. 

An  important  feature  that  should  never  be  lost 
sight  of  is  the  psychology  of  the  patient.  Those  who 
accept  the  method  reluctantly,  and  are  anxious,  nerv- 
ous, and  hyper-sensitive,  are  the  difficult  subjects; 
most  of  these,  however,  once  the  operation  has  been 
satisfactorily  concluded,  express  themselves  as  com- 
pletely satisfied. 

On  the  other  hand,  there  are  those  who,  familiar 
with  the  distress  of  the  after-effects  of  general  nar- 
cosis, welcome  the  new  mode  of  procedure  and  make 
most  satisfactory  subjects.  The  mental  attitude  of 
the  patient  has  almost  as  much  to  do  with  the  suc- 
cess of  the  operation  as  the  ability  of  the  operator. 

The  Time  Element. — About  the  same  time  is 
consumed  in  the  administration  of  regional  anes- 
thesia as  in  that  of  general  narcosis.  About  ten 
or  fifteen  minutes  are  required  for  an  experienced 
assistant  to  perform  the  necessary  injections  in  the 
former  procedure,  and  another  ten  minutes  must 
then  elapse  for  the  full  effect  to  become  estab- 
lished. About  the  same  length  of  time  is  re- 
quired to  obtain  the  complete  efTects  of  inhalation 
anesthesia. 

Where  the  operator  is  dealing  with  a  private 
case,  it  is  not  often  that  a  few  moments  more  or  less 


10  REGIONAL   ANESTHESIA. 

will  particularly  interfere  with  the  type  of  technique 
he  may  select,  that  which  is  best  in  his  opinion 
governing   the   choice. 

In  hospital  service,  where  several  cases  are  to  be 
operated  upon,  it  is  essential  to  have  an  experienced 
assistant  for  the  advance  preparation  of  the  cases. 
This  likewise  applies  in  the  administration  of  a 
general  anesthetic. 

In  any  event,  the  loss  of  a  few  moments'  time  is 
not  to  be  considered  in  comparison  with  the  benefits 
to  the  patient  that  attend  the  regional  form  of 
anesthesia. 

The  Claim  that  Regional  Anesthesia  is  not  Equally 
Adapted  for  all  Operations. — The  beginner  in 
regional  anesthesia  may  better  satisfy  both  himself 
and  the  patient  by  giving  ethyl  chloride,  ether,  or  chlo- 
roform to  complete  the  anesthesia  if  there  is  complaint 
to  any  degree. 

Mixed  anesthesias,  although  not  attractive  in 
theory,  cause  less  shock  than  simple  narcosis. 

If  a  preparatory  injection  of  morphine-scopola- 
mine  is  administered  before  the  introduction  of  the 
procaine-suprarenin  and  the  operation  is  completed 
with  the  aid  of  the  inhalation  narcotics  referred  to, 
the  patient  will  be  affected  less  than  by  simple  nar- 
cosis, i.e.,  he  will  be  less  affected  by  three  agents  than 
by  one.  For  this  a  theoretical  explanation  is  avail- 
able, but  such  explanation  is  not  so  important  as  the 
fact  itself  which  has  been  learned  by  actual  ex- 
perience. 

In  trephining  operations,  goiter  excisions,  total 
laryngectomies,  prostatectomies,  operations  for  hem- 


GENERAL   CONSIDERATIONS,  H 

orrhoids,  radical  cure  of  hernia,  and  costal  resec- 
tions, regional  anesthesia  is  a  most  gratifying  pro- 
cedure. With  increasing  experience,  furthermore, 
the  operator  will  learn  the  details  of  technique  that 
render  this  form  of  anesthesia  applicable  to  any  and 
all  operations. 


CHAPTER    11. 

ARMAMENTARIUM. 

Syringes. — The  operator  should  have  at  his  dis- 
posal Luer's  all  glass  morphine  syringe  of  i-  to  2-  mil 
capacity,  and  also  a  metal  and  glass  syringe  of  10- 
mil  capacity. 

My  earlier  experience  was  with  the  Record 
syringe,  which  is  very  serviceable,  but  more  lately  I 
have  been  led  to  substitute  the  Collin  all  metal 
syringe  (Fig.  i),  which  is  to  be  preferred  in  that  it 
is  both  short,  powerful,  and  unbreakable.  The  syringe 
should  be  thoroughly  water  tight  and  provided  at  its 
top  with  lateral  handles  by  means  of  which  a  firm 
hold  can  be  secured. 

Needles. — These  should  be  of  small  caliber,  with 
a  short-beveled  point.  The  smaller  the  caliber  of  the 
needle,  the  less  painful  its  introduction.  Needles  of 
the  smallest  caliber  and  with  long,  fine  points 
should  be  particularly  employed  for  the  formation 
of  the  dermal  wheals   later  to  be   described. 

Platinum  needles  are  expensive  and  soon  be- 
come blunted  at  the  point.  Steel  needles  are  finer 
pointed  and  remain  sharp  longer,  but  are  prone 
to  rust  and  are  easily  broken.  I  have  found  it 
best  to  employ  either  fine  steel,  or  nickel  needles. 
The  latter  remain  sharp  and  in  good  condition  the 
longest.  The  junction  between  the  nozzle  of  the 
(12) 


ARMAMENTARIUM. 


13 


syringe  and  the  needle  must  permit  of  no  leakage, 
the  needle  remaining  in  situ  while  the  syringe  is 
repeatedly     removed     for     refilling.       The     smooth 


Fig.  1. — A  10-mil  metal  syringe  of  Collin  make,  short, 
strong,  unbreakable,  handy  and  with  graduated  plunger  rod. 
The  lateral  socket  enables  the  operator  to  make  injections 
parallel  with  the  surface  while  using  a  straight  needle. 


14  REGIONAL   ANESTHESIA. 

socket  type  should  be  chosen  rather  than  the  screw 
or  bayonet   form. 

We  employ  only  the  straight  form  of  needle. 
It  is  less  expensive  and  more  easily  obtained,  and 
when  once  one  is  accustomed  to  its  use,  it  answers 
every   purpose. 

There  should  be  provided  needles  of  four 
lengths,  viz.,  3,  6,  9,  and  12  centimeters  (Fig.  2).  The 
3-centimeter  needle  is  used  in  making  the  dermal 
wheals.  It  should  be  sharp  pointed.  The  12- 
centimeter  needle  is  seldom  used — chiefly  for  pre- 
sacral injections.  The  6-  and  9-  centimeter  needles 
serve  for  all  general  purposes. 

To  mark  the  exact  depth  to  which  the  needle 
is  to  be  introduced,  the  operator  may  make  a 
shield  from  a  piece  of  boiled  cork  or  a  square 
of  rubber  sheeting,  to  be  adjusted  upon  the  needle 
at   the   point   desired. 

The  instruments  and  receptacles  for  the  solu- 
tion should  be  sterilized  in  plain  boiling  water, 
without   addition   of   any   chemical   agent   whatever. 

Anesthetic. — As  anesthetic  we  have  been  using 
neocdine-siirrenine  (Corbiere),  a  French  prepara- 
tion which  replaces  with  perfect  satisfaction  the 
German  product  novocaine-adrenalin.  In  prepar- 
ing a  considerable  amount  of  the  solution,  to  be 
kept  for  some  hours,  it  is  best  to  use  the  pure 
procaine,^  to  which  can  be  added  immediately  be- 
fore use  the  required  quantity  of  adrenin. 


1  Procaine  being  the  term  now  in  general  use  in  the  United  States 
m  place  of  neocaine  or  novocaine,  this  term  will  be  regularly  employed 
hereinafter. 


ARMAMENTARIUM. 


15 


The  formulas  of  the  mixtures  used  are  as   fol- 
lows:     (i)    25    drops   of    I    to    1000   adrenin    solu- 


tion to  200  mils  of  Yi   per  cent,  procaine  solution; 


Fig.  2. — Four  steel  needles,  respectively,  12,  9,  6,  and  3  centi- 
meters in  length.  Each  needle  is  provided  with  a  mandril. 
Actually  the  needles  are  twice  as  fine  as  they  are  represented 
in  this  illustration. 


{2.)  25  drops  of  adrenin  to  lOO  mils  of  i  per 
cent,  procaine;  (3)  25  drops  of  adrenin  to  50  mils 
of  2   per   cent,   procaine;    (4)    25   drops  of  adrenin 


16 


REGIONAL   ANESTHESIA. 


solution  to  25  mils  of  4  per  cent,  procaine. 
Twenty-five  drops  of  the  adrenin  solution  is  the 
equivalent   of    i    milligram   of    adrenin. 

We  use  the  4  per  cent,  solution  but  seldom, 
for  the  cranial  nerves  and  brachial  plexus;  the  2 
per  cent,  solution  frequently,  as  a  rule  for  the 
nerve    trunks;   but   the    i    per    cent,    and    especially 


Fig.  3. — From  left  to  right,  an  ampoule  of  saline  solution 
for  dissolving  the  procaine ;  a  tube  containing  2  capsules  of 
procaine  in  powder  form  and  3  sealed  flasks  containing  150 
grams  of  Y^  per  cent,   solution. 


the  Yi  per  cent,  solutions  are  those  most  com- 
monly  employed,   the   latter   for   all   infiltrations. 

It  is  far  cheaper  to  prepare  the  solution  as  re- 
quired than  to  buy  it   read}^  made. 

The  adrenin  and  procaine  come  in  glass  am- 
poules. On  the  evening  of  the  day  preceding  the 
operation  these  are  dissolved  in  boiled  salt  solu- 
tion. Even  more  convenient  are  the  procaine  tab- 
lets  which   can  be   dissolved   in  boiled   salt   solution 


ARMAMENTARIUM.  17 

and  kept  until  needed  for  use,  when  the  required 
amount  of   adrenin   is  added. 

It  is  inadvisable  to  attempt  to  sterilize  the 
solution  after  the  mixture  has  been  made;  this 
should  be  done  beforehand.  The  procaine  adrenin 
should  be  added  to  a  hot  solution  (35°  C.)  to  in- 
sure  its   ready   dissolution. 

The  high  percentage  solutions  should  be  in- 
jected very  slowly,  and  in  amounts  never  exceed- 
ing 20  to  40  mils  of  the  Yi  per  cent,  solution. 
We  have  employed,  however,  as  much  as  300  mils 
without   any   harmful    effect. 

In  removal  of  the  breast  for  cancer,  as  much 
as  250  to  300  mils  may  be  employed;  most  of  it 
escapes  after  the  primary  incision  has  been  made. 

For  anesthetizing  the  viscera,  and  especially  the 
peritoneal  ligaments,  the  omental  tissues,  the  meso- 
appendix,  the  mesentery,  and  the  sero-vascular 
pedicles,  we  often  employ  (following  the  advice 
of  Crile,  of  Cleveland)  a  i  per  cent,  solution  of 
quinine  and  urea  hydrochloride,^  injecting  as 
much  as  100  grams  in  addition  to  the  solution  of 
procaine-adrenin  already   used. 


•   General   Technique. 

Theoretically,  regional  anesthesia  and  anesthe- 
sia by  infiltration,  according  to  the  procedure  of 
Reclus,  are  Hvo  different  methods.  Practically, 
neither   of   them   excludes    the   other,    but,    in    fact. 


1  The  profkict  termed  by  Corbiere  uroca'ine. 

2 


18  REGIONAL    ANESTHESIA. 

they  supplement  each  other  and  are  often  em- 
ployed in  combination. 

The  principle  of  regional  anesthesia  is,  not  to 
infiltrate  the  field  of  operation  or  surrounding  tis- 
sues, but  to  secure  insensibility  by  directly  inject- 
ing the  nerves  distributed  to  the  region  or  tissues 
surrounding  these  nerves.  To  each  region  cor- 
responds a  special  technique,  appropriate  for  the 
-insensibilization  of  the  nerves  in  that  region,  and 
with  which  the  operator  must  be  familiar  in  order 
to    succeed. 

Necessity  of  Perfect  Asepsis  in  Regional  Anes- 
thesia.— In  making  the  injections,  the  operator 
proceeds  without  gloves,  but  with  hands  well  dis- 
infected, as  for  an  ordinary  minor  operation.  The 
instruments  and  solution  must  be  sterilized.  Care 
is  taken  not  to  dip  the  syringe  into  the  glass  re- 
ceptacle containing  the  solution,  particularly  if  the 
syringe  has  come  in  contact  with  the  fingers  of  the 
operator  and  the  patient's  skin.  A  special  needle 
is  reserved  for  drawing  up  the  fluid  into  the 
syringe.  It  should  be  constantly  borne  in  mind 
that  ungloved  hands  are  never  aseptic  any  more 
than   is  the  patient's   skin. 

In  practice,  the  two  methods,  nerve-block- 
ing and  infiltration,  are  usually  employed  together, 
the   one   aiding   and   completing  the   other. 

With  few  exceptions,  e.g.,  anesthesia  of  the 
meso-appendix  with  urocaine  before  its  section,  or 
anesthesia  of  the  omental  tissues,  complete  induc- 
tion of  anesthesia  precedes  the  operative  pro- 
cedure.     No   injection   should   be   made   during  the 


ARMAMENTARIUM.  19 

Operation,  which  is  performed  as  though  the  pa- 
tient were  under  general  anesthesia;  the  anesthe- 
sia should  be  complete  when  the  patient  is  brought 
to  the  surgeon,  and  there  should  be  no  more  ques- 
tion of   it   during  the  operation. 

The  method  does  not  in  any  way  prolong  the 
duration  of  the  operation,  nor  does  it  leave  the 
operative  field  or  the  incision  any  longer  exposed 
to   the   air. 

Preparation  of  the  Field  of  Operation. — Before 
the   injections   are   begun,   the   skin   of   the   field   of 


Fig.  4. — A  5-mil  syringe  of  metal  and  glass. 

Operation  should  be  disinfected  with  a  5  per  cent. 
tincture  of  iodine.  When  the  injections  have  been 
completed  the  region  should  be  rubbed  with  alco- 
hol, which  will  remove  the  few  drops  of  liquid 
injected  and  the  excess  of  iodine.  Next  come  the 
final  preparation  of  the  patient,  the  covering  of 
the  operative  field,  and  the  preparation  of  the 
operator  and  his  assistant — during  which  time  the 
tissues   will   have   become   completely   anesthetized. 

The  Injections. — The   syringe    (Fig.   4)    is   held 
with   the   thumb   and   the   second  and   third  fingers 


20 


REGIONAL   ANESTHESIA. 


of  the  right  hand  (Fig.  5).  By  virtue  of  the 
flexibihty  of  the  operator's  wrist,  all  pressure 
other  than  that  in  the  direct  line  of  the  needle 
is  obviated,  to  avoid  breaking  of  the  needle.  The 
latter   should  never  be   inserted   down  to  its  flange. 


Fig.  5. — Shows  the  manner  of  holding  the  syringe 
during  injection.     (Reclus.) 


The  plunger  should  be  pushed  home  during  the 
introduction  or  the  removal  of  the  needle,  the  two 
acts  being  simultaneous  (continuous  injection  of 
Reclus).  The  minimum  quantity  of  ^  per  cent, 
solution  to  be  injected  is  i  mil  per  centimeter  of 
distance;  for  the   i   per  cent,   solution,   slightly  less. 


ARMAMENTARIUM.  21 

The  slight  edema  resulting  from  the  subcutane- 
ous injection  raises  the  overlying  skin,  and  the 
region  injected,  rendered  ischemic  by  the  adrenin, 
becomes  definitely  pale. 

Difficulties  arising  from  edema  of  the  super- 
ficial tissues  may  be  obviated  by  commencing  with 
deep   injections. 

Skin  Wheals. — In  infiltrating  a  given  region, 
it  is   often  necessary   to   make   successive   injections 


Fig.  6. — Formation  of  the  dermal  wheal.  (Pauchet.)  The 
bevel  of  the  needle  point  is  directed  upward  and  should  dis- 
appear entirely  in  the  dermis  before  the  intradermal  injection 
is  made. 


with  needles  chosen  progressively  longer.  Again 
it  is  indispensable  to  mark  beforehand  the  sites 
for  these  injections  by  the  formation  of  "intra- 
dermal wheals''  which  will  render  the  skin  insen- 
sitive to  the  introduction  of  the  needle.  The 
wheal  consists  essentially  of  an  intradermal  infil- 
tration  of   small   diameter    (Fig.    6). 

A  fine,  short  needle  mounted  on  a  syringe  filled 
with  ^  per  cent,  solution  is  introduced  almost 
parallel    with    the    skin    surface,    with    the    bevelled 


22  REGIONAL   ANESTHESIA. 

edge  upward,  directly  into  the  thickness  of  the 
skin.  As  soon  as  tlie  opening  of  the  needle  has 
disappeared,  the  plunger  is  pushed  down  to  drive 
in  a  little  of  the  solution.  A  white  swelling  in- 
stantly forms  in  the  tissues,  which  take  on  the 
aspect  of  "orange  skin."  One  or  more  wheals,  ac- 
cording to  requirements,  are  thus  marked  out,  and 
through  them  the  needles  are  subsequently  intro- 
duced   for    all    the    necessary    injections. 

Each  injection  should  be  made  into  the  skin 
proper,  without  passage  through  into  the  subcu- 
taneous cellular  tissue,  which  is  made  evident  by 
disappearance  of  resistance  to  the  needle.  If  the 
skin  of  the  region  is  delicate  and  movable,  a  fold 
of  it  should  be  taken  up  between  the  left  thumb 
and  index  finger  and  the  needle  introduced  at  the 
top  of  this  fold,  meanwhile  firmly  held.  The  pain 
is  very  slight  and  evanescent,  disappearing  as 
soon   as   the   anesthetic   solution   has   been   injected. 

Injection  at  Right  Angles. — When  it  is  neces- 
sary to  make  an  incision  at  right  angles,  as  for 
blood  transfusion,  the  intradermal  injections  of 
Reclus  are  superfluous,  subcutaneous  injection  be- 
ing sufficient  to  anesthetize  the  subcutaneous  tis- 
sue. An  intradermal  wheal  is  made  at  one  end 
of  the  incision;  then,  with  a  syringe  provided  with 
a  long  needle,  an  injection  is  made  through  the 
wheal,  under  the  skin,  the  needle  being  inserted 
parallel  to  the  surface  in  the  subcutaneous  tissues 
to  the  full  length  of  the  proposed  incision  or  the 
distance  that  the  needle  permits.  Inadvertent 
emergence  of  the  point  of  the  needle  from   within 


ARMAMENTARIUM. 


23 


outward   should   be   avoided,    as   it   is   more   painful 
than  entrance   of   the  needle   from   without   in. 


Fig.  7. — Subcutaneous  infiltration  of  a  straight  band  of  skin 
through  two  dermal  wheals  at  either  extremity.  (Recius.)  A 
needle  traverses  the  dermal  wheals  without  pain  when  the  in- 
jection is  made  slowly.  One  mil  of  procaine-adrenin  solution  to 
each  centimeter  of  distance.  The  illustration  presents  both  a 
front  and  a  side  view,  with  curved  or  angular  incisions. 


After  a  few  minutes  the  skin  covering  the  in- 
jected tissue  will  have  become  insensible,  the  solu- 
tion having  anesthetized  not  only  the  subcutaneous 


Fig.  8. —  (A)  The  injections  can  be  made  through  2  wheals 
or  1  wheal.  (B)  Continuous  line  of  injections,  as  indicated 
by  the  directions  of  the  arrows.      (Pauchet.) 


tissue,  but  also  the  nerve  filaments  of  the  adjacent 

skin.     This  is  the  simplest  form  of  local  anesthesia. 

If    one    injection    or    one    needle-length    is    not 

sufflcient,    one    should    make    two    wheals,    one    at 


24 


REGIONAL   ANESTHESIA. 


each    extremity    of    the    proposed    incision — or    as 
many  as  may  be   required — and  infiltrate   from  the 


Fig.  9. — Injections  surrounding  a  field  of  operation.  {Rec- 
tus.) The  6  wheals  are  united  by  bands  of  infiltration  as  in- 
dicated by  the  arrows. 

two  ends  (Fig.  y).  Curved  incisions  or  injections 
at  right  angles  require  an  injection  at  the  summit 
of  the  curve  or  angle,  or  two  injections    (Fig.   8). 


Fig.  10. — Shows  the  method  of  infiltrating  the  curved  sur- 
face of  the  forearm  through  4  dermal  wheals,  each  wheal  be- 
ing placed  at  the  summit  of  the  curve.  (Pauchet.)  The 
injections  are  made  in  the  directions  shown  by  the  arrows. 


The    curvature    of    the    body    surface    prevents    the 
penetration   of    a   needle    at    right    angles    into    the 


ARMAMENTARIUM.  25 

skin  at  a  single  injection.  Thus,  in  injecting  the 
subcutaneous  tissues  around  the  forearm,  four 
wheals  through  each  of  which  the  needles  are 
entered  from  both  sides  (Figs.  9  and  10)  are 
required. 

Infiltration  of  a  subcutaneous  band  perpendicu- 
lar to  the  axis  of  the  limb  anesthetizes  not  only 
the   skin   immediately   covering   the   injected   tissue, 


Fig.  11. — Infiltration  of  a  subcutaneous  surface  by  injec- 
tions radiating  from  dermal  wheals  1  and  2  (for  the  removal 
of  skin  grafts,  excision  of  a  chancroid,  etc.).     (Pauchet.) 

but  also  all  the  subcutaneous  tissues  situated  dis- 
tally  to  the  injected  region  {circular  anesthesia). 
Surface  Infiltration. — This  consists  in  the  in- 
filtration of  an  area  of  subcutaneous  tissue  by  i, 
2,  or  more  wheals.  Through  each  of  these  points 
a  long  needle  is  introduced  in  all  directions,  anes- 
thetizing the  whole  of  the  cutaneous  surface  bounded 
by  the  wheals.  This  procedure  is  serviceable  for 
the  preparation  of  Thiersch  skin  grafts  (Fig.    ii). 


26  REGIONAL   ANESTHESIA. 

For  the  removal  of  skin  tumors,  subcutaneous 
infiltration  of  the  base  of  the  neoplasm  suffices, 
without   injection  of  the  tumor   itself    (Fig.    12). 

Anesthesia  of  Mucous  Membranes. — The  same 
directions  hold  good  in  the  case  of  mucous  mem- 
branes, but  the  wheals  are  unnecessary.  One  simply 
makes  a  sub-membranous  injection,  which  renders 
the   adjacent  area   of  mucous  membrane   insensible. 

Circular  Injections. — In  certain  parts  of  the 
body    the    sensory    nerves    of    the    skin    and   of    the 


Fig.    12. — Infiltration   of   the   pedicle   of   a   skin   tumor 
(moUuscum).     (Pauchet.) 

fascia  are  continuous.  Large  portions  of  the  body 
surface  do  not  have  special  nerves  from  the  sub- 
aponeurotic region.  Hence  it  is  not  always  neces- 
sary, in  anesthetizing  the  skin  and  subcutaneous 
tissues,  to  inject  the  cellular  tissue;  in  many  in- 
stances a  subcutaneous  injection  surrounding  the 
latter  suffices.  This  is  what  is  termed  circjilar 
injection  (Fig.  13).  At  i  and  2,  two  injections 
are  made;  the  subcutaneous  tissue  is  infiltrated 
from  I  to  3,  I  to  4,  2  to  3,  and  finally  from  2 
to  4,   so   that   the   operative  field   is    surrounded   by 


ARMAMEi\TARIUM. 


27 


a  subcutaneous  wall  of  infiltration  in  the  form  of 
an  elongated  lozenge.  The  long  diameter  of  the 
lozenge-shaped  area  corresponds  to  the  direction 
of  the  incision  to  be  subsequently  made.  Injec- 
tions may  instead  be  made  at  3  and  4,  if  it  is  more 


Fig.  13. — Subcutaneous  quadrilateral  infiltration  through 
1  and  2,  in  the  shape  of  a  lozenge,  1,  2,  3,  and  4,  following 
the  direction  of  the  arrows.      (Reclus.) 


convenient.  The  wall  surrounding  the  operative 
field  may,  as  desired,  be  made  in  the  shape  of  a 
square,  circle,  etc.  The  number  of  wheals  to  be 
prepared  for  the  injections  depends  upon  the 
shape  and  dimensions  of  the  operative  field  (Fig.  9). 
Tn   some   parts   of   the  body,   the   sensory  nerves 


28 


REGIONAL   ANESTHESIA. 


run  a  prolonged  subcutaneous  course,  supplying 
both  the  surface  and  the  deep  tissues.  As  regards 
the  upper  part  of  the  head,  the  sensory  nerves  of 
the  skin,  pericranium,  periosteum,  and  bones  all 
course  through  the  subcutaneous  tissue  at  the 
level    of    the    base   of    the    cranium    and    forehead. 


Fig.  14. — Anesthesia  for  tapping,  as  in  ascites  or  pleurisy, 
or  for  the  introduction  of  a  radium  tube  into  a  tumor. 
(Reclus.) 


Consequently  a  simple  circular  subcutaneous  injec- 
tion will  desensitize  large  areas  on  the  head,  in- 
cluding the  bones.  Anesthesia  of  a  finger  is  in- 
stituted on  the  same  principle.  The  subcutaneous 
tissue  of  the  first  phalanx  contains  all  the  nerves 
of  the  finger.  If  a  ring  be  injected  around  the 
base  of  the  finger,  the  entire  finger  will  be  desen- 
sitized. 


ARMAMENTARIUM.  29 

Deep  Infiltration. — Simple  circular  subcutaneous 
injections  are  adequate  only  in  parts  of  the  body 
in  which  the  nerve  supply  is  disposed  as  in  the 
parts  above  mentioned.  They  are  not  adequate  when 
the  nerve  supply  is  deeply  seated.  Thus,  on  the 
chin,  circular  injection  of  an  operative  field  in  the 
center  of  which  emerges  the  mental  nerve  would 
yield  only  an  incomplete  anesthesia.  One  of  the 
primary  essentials  in  inducing  regional  anesthesia 
is  a  systematic  infiltration  of  any  thick  bed  of 
tissue  composed  of  different  layers.  An  example 
of  such  anesthesia  in  its  simplest  form  is  that  of 
the  line  of  puncture  in  ascites  or  pleural  effusion 
(Fig.    14). 

The  point  of  the  injection  is  marked  by  a 
wheal,  a  needle  of  a  convenient  length  inserted, 
and  an  injection  made  without  interruption  down 
to  the  subpleural  or  subperitoneal  tissues.  The 
pleural  and  the  peritoneal  nerves  require  separate 
infiltration  because  they  course  in  the  subpleural 
or   subperitoneal   tissues. 

Infiltration  by  Layers. — A  systematic  infiltra- 
tion of  a  mass  of  tissues  is  that  which  will  act 
upon  all  the  layers  of  tissue  therein  contained 
(Fig.  15).  One  should  begin  with  deep  injections 
and  finish  with  subcutaneous  ones.  The  needle, 
through  a  wheal,  is  inserted  in  a  perpendicular 
direction  to  the  deepest  point.  It  is  then  brought 
up  to  the  subcutaneous  tissue  and  inserted  again, 
injecting  obliquely  toward  the  middle  of  the  tis- 
sue-mass to  be  infiltrated,  and  so  on.  The  last 
injection  is  made  in  a  parallel   direction  under   the 


30  REGIONAL    ANESTHESIA. 

skin.  The  fluid  is  injected  continuously  during 
the  introduction  and  withdrawal  of  the  needle.  If 
the  length  of  the  needle  will  allow,  a  single  wheal 
at  one  extremity  or  in  the  middle  suffices. 

At  no  point  in  the  body  are  subperiosteal  in- 
jections necessary  for  desensitization  of  the  perios- 
teum, which  receives  its  nerves  from  without  and 
becomes  desensitized  through  the  influence  of  the 
fluid  in   the  tissues   which   cover   it. 


< ^A    a 


"i^immmmm^^mMm^^^m^m^ 


Fig.  15. — Osteotomy  of  the  femur.  {Pauchct.)  Anesthesia 
of  the  diaphysis.  Make  two  wheals,  1  and  2.  From  these 
two  points  make  the  injections  above  and  below  as  shown  by 
the  arrows,  forming  a  liquid  sheath  round  the  periosteum.  If 
the  ears  of  the  patient  be  stopped  with  cotton,  one  may  saw 
or  break  the  bone  without  causing  him  pain  or  nervous  dis- 
turbance. 

Infiltration  of  thick  masses  of  tissues,  as  just 
described,  demands  a  certain  amount  of  practice. 
One  must  learn  to  feel  with  the  point  of  the 
needle.  One  must  know  at  every  instant  which 
anatomical  layer  is  being  entered.  The  hand  soon 
becomes  accustomed  to  recognizing  when  the  needle- 
point is  traversing  a  resistant  layer  and  when  it 
again  passes  into  a  layer  of  soft  tissues.  Injec- 
tion through  the  muscular  aponeuroses  generally 
causes    slight   pain.      Therefore,    one    should    inject 


ARMAMENTARIUM. 


31 


the  fluid  progressively  as  the  needle  is  being  in- 
troduced, following  the  method  of  Reclus.  By 
this  procedure  injection  of  a  large  amount  of  the 
anesthetic  into  a  vein  is  obviated,  while  at  the 
same  time,  continuous  injection  insures  an  equal 
distribution    of    the    solution.      When    an    injection 


Fig.  16. — Infiltration  of  a  layer  of  soft  tissue  through  der- 
mal wheals  1  and  2.  (Pauchet.)  The  injections  follow  the 
direction  of  the  arrows  down  to  the  bone,  the  last  made  being 
those  entering  the  subcutaneous  cellular  tissue, 

in  the  proximity  of  large  vessels  is  required,  it 
is  best  to  introduce  the  needle  independently  of 
the  syringe  and  to  inject  the  fluid  only  if  blood 
fails  to  flow  from  the  needle  lumen.  Puncture  of 
a  large  artery  or  vein,  is,  of  course,  to  be  avoided, 
but  it  is  altogether  free  of  danger  if  fine  needles 
are  employed. 

Injection    of    a    small    area    suffices    whenever    a 
simple    incision   in  healthy   tissue   is   alone   required. 


32  REGIONAL   ANESTHESIA. 

e.g.,  for  the  extraction  of  a  foreign  body  from 
a  definitely  known   situation. 

Regional  anesthesia  likewise  permits  of  secur- 
ing  insensibility   of    large   fields    of    operation. 

Often  infiltration  of  a  single  locality  will  des- 
troy sensation  in  most  of  the  nerves  leading  to 
the  field  of  operation.  This  is  the  case,  e.g.,  in 
operations  at  the  front  of  the  neck,  or  for  the 
cure    of    femoral    or    inoxiinal    hernia.      At .  other 


¥\g.  17. — Pyramidal  injections.  (Pauchet.)  Through  the 
dermal  wheals  1,  2,  3,  and  4,  one  may  painlessly  infiltrate  four 
triangular  layers,  union  of  which  isolates  a  pyramid  of  anes- 
thetized tissue.      (Removal  of  a  shell   fragment,   etc.) 

times,  one  must  infiltrate  simultaneously  all  the 
layers    surrounding    the    operative    field. 

The  technique  will  be  readily  understood  upon 
inspection  of   a   few  diagrams. 

Fig.  1 6  represents  a  pyramid.  Its  summit,  5, 
is  deeply  situated  beneath  the  center  of  the  opera- 
tive field,  while  its  base,  i,  2,  3,  and  4,  is  at  the 
cutaneous  surface.  Its  lateral  surfaces  bound  the 
field  of  operation;  it  is  these  sides  which  require 
to  be   injected. 

Dermal  wheals,  i,  2,  3,  and  4,  are  first  marked 
out.      Through    each    of    these    a    long    needle    is 


ARMAMENTARIUM.  33 

introduced  at  first  toward  point  5,  then  toward 
variotis  points  situated  on  the  lateral  surfaces,  e.g., 
from  I  to  7,  4  to  7,  4  to  6,  3  to  6,  3  to  9,  2  to 
9,  etc.  The  field  of  operation  thus  becomes  de- 
sensitized without  having  been  directly  reached  by 


Fig.  18. — Boat-shaped  infiltration  through  dermal  wheals 
1  and  2.  Injection  of  four  quadrilateral  surfaces,  permitting 
the  removal  of  a  tumor  or  foreign  body.     (Pauchet.) 


the  anesthetic.  Often  two  surface  injections  suf- 
fice to  encompass  the  area  perfectly.  In  other 
cases  more  than  four  are  required,  and  the  de- 
signs for  injection  assume,  according  to  the  ex- 
tent of  the  operative  field,  many  varied  forms: 
cone,  jjase  of  a  cone,  a  boat-shaped  solid,  etc. 
In  Fig.    17  there  are   two   points  of  entrance,   viz., 


34  REGIONAL   ANESTHESIA. 

I  and  2,  through  which  one  injects  toward  3,  4, 
5,  6,  and  7,  and  finally  infiltrates  the  subcutaneous 
tissue.  Fig.  18  shows  a  field  of  operation  on  a 
limb;  by  the  type  of  anesthesia  depicted  the  bone 
may  be  desensitized.  For  all  these  injections  a  }^ 
per  cent,  solution  is  used.  A  more  concentrated 
solution,  from  i  per  cent,  to  4  per  cent.,  injected 
in  small  amounts,  is  preferable  wherever  large 
quantities  of  liquid  would  lead  to  difficulty  or  dis- 
comfort, as  in  the  orbit,  eyelids,  foreskin  (circum- 
cision),  fingers,   etc. 

Small  amounts  of  these  concentrated  solutions 
oftentimes  exert  a  prolonged  efTect.  Injection 
of  a  small  quantity  of  anesthetic  may  afifect  not 
only  the  region  injected  but  also  the  trunk  of  a 
nerve    supplying   surfaces    at    a    distance. 

Perineural  or  Endoneural  Injection  by  the  Sub- 
cutaneous Route. — Anesthesia  of  a  large  nerve- 
trunk  is  often  combined  with  peripheral  infiltra- 
tion, and  is  governed  by  certain  definite  principles. 
In  the  first  place,  the  point  of  the  needle  must 
be  brought  in  contact  with  the  nerve.  This  is 
readily  done  whenever  the  nerve  is  situated  near  a 
bone  constituting  a  landmark,  as  in  the  case  of 
the  ulnar  nerve,  but  is  more  difficult  when  such 
landmarks  are  absent  and  when  the  nerve  is  sit- 
uated in  the  midst  of  soft  tissues.  One  of  the 
most  reliable  indications  of  the  needle  reaching 
the  nerve  is  afforded  by  a  paresthesia  radiating 
toward  the  periphery.  The  sharp  pain  referred 
in  the  direction  of  the  nerve  distribution  demon- 
strates  the   contact   of   the   needle   with   the   nerve. 


ARMAMENTARIUM.  35 

The  patient  should  therefore  be  told  of  this  be- 
fore the  needle  is  introduced  and  should  let  the 
operator  know  as  soon  as  the  paresthesia  is  ex- 
perienced. 

For  the  injection  of  large  nerves  it  is  well  to 
use  from  i  to  5  mils  of  a  concentrated  solution, 
2   to   4  per   cent.,   of   procaine-adrenin. 

The  length  of  time  one  must  wait  after  having 
made  the  injection  depends  upon  the  manner  in 
which  the  nerve  has  been  reached.  If  the  needle 
has  been  introduced  into  the  nerve  root,  as  occurs 
in  the  case  of  the  fifth  nerve,  abolition  of  sensa- 
tion is  instantaneous.  If  the  anesthetic  has  merely 
been  injected  around  the  nerve  trunk,  5  to  20 
minutes  elapse  before  complete  insensibility  is 
established. 

Direct  Endoneural  Injection. — Exposed  nerve- 
trunks  may  be  desensitized  by  the  injection  of  a 
little  4  per  cent,  solution — viz.,  i  ampoule — using 
a  3-centimeter  needle.  This  procedure  is  very 
satisfactory  for  operations  on  nerves.  The  opera- 
tor begins  by  incising  the  layers  of  tissues  cover- 
ing the  nerve,  as  these  have  already  been  injected 
with  procaine-adrenin.  When  the  nerve  has  been 
located  beneath  the  incision,  he  injects  directly 
into  the  trunk  the  contents  of  a  2-mil  ampoule 
of   the   4   per   cent,    solution. 

Choice  of  Procedure. — The  nature  of  the  af- 
fection to  be  operated  for — wound,  removal  of 
foreign  body  or  of  an  inflammatory  or  neoplastic 
tumor — governs  the  form  of  the  injection,  and 
one  must   always   be   careful   to   desensitize   a   large 


36  '  REGIOxNAL   ANESTHESIA. 

enough  area  in  order  to  be  prepared  for  all  event- 
ualities and  have  a  certain  degree  of  latitude  dur- 
ing the  operation.  One  should  avoid  injecting 
the  line  of  incision,  and  keep  always  at  a  certain 
distance  from  diseased  tissues,  particularly  if  in- 
fected. A  well  defined  furuncle  should  be  en- 
circled by  an  injection  in  the  form  of  a  pyramid, 
at  quite  a  distance  from  the  inflamed  tissues. 
Difl:use  phlegmons  lend  themselves  to  local  anes- 
thesia only  if  it  is  possible  to_  desensitize  them  at 
a  distance  from  the  field  of  operation.  Malig- 
nancy of  a  tumor  is  no  contraindication  to  regional 
anesthesia  if  the  entire  field  can  be  desensitized 
without  an  injection  in  contact  with  the  tumor. 
One  must  not  forget  the  temporary  ischemia 
which  adrenin  produces  in  the  infiltrated  area. 
This  ischemia  is  often  an  advantage,  as  it  reduces 
hemorrhage  to  the  point  of  totally  changing  the 
aspect  of  certain  operations,  such  as  those  for 
hemorrhoids,  resection  of  the  superior  maxillary 
or  of  the  tongue,  laryngectomy,  etc.  But  in  plas- 
tic operations  one  must  be  careful  not  to  ischemize 
the  base  of  the  flap  to  be  turned  back,  as  this 
would   compromise  its   vitality. 

For  plastic  operations  of  the  face,  strong  solu- 
tions of  procaine  without  adrenin  should  be  used; 
the  solution  runs  out  with  the  blood,  and  the  anes- 
thesia need  not  last  long,  as  these  operations  are 
always  of  short  duration. 


CHAPTER    III. 

CRANIAL    OPERATIONS. 

The  sensory  nerves  supplying  the  skin  of  the 
forehead,  the  temples,  and  the  scalp,  all  pass  at 
the  level  of  a  line  encircling  the  skull  from  the 
eyelids  to  the  external  occipital  protuberance  (Fig. 
19).      From   there   they   branch    to    the    summit   of 


Fig.  19. — Nerve  supply  of  the  scalp.  (Hirschfeld.)  Injec- 
tion of  a  1  per  cent,  solution  of  procaine-adrenin  on  a  line 
completely  surrounding  the  head  above  the  ears  and  eyebrows 
completely  desensitizes  the  nerve  supply  to  the  scalp. 


the  cranium,  where  .  they  spread  out  under  the 
skin  and  the  cranial  aponeurosis.  It  is  therefore 
very  easy  to  anesthetize  the  entire  cranium  by  a 
circular    injection    at    this    line.       The    nerves    re- 

(37) 


38 


REGIONAL   ANESTHESIA. 


ferred  to  supply  not  only  the  skin  and  pericranium, 
but  also  the  bones  of  the  summit  of  the  cranium 
and  their  periosteum.  The  dura  mater  is  not  sen- 
sitive to  pain  except  below  the  base  of  the  skull; 
therefore  operations  upon  the  summit  are  painless. 


Fig.  20. — Tumor  of  the  scalp.  (Pauchet.)  Whether  the 
condition  be  a  wen,  a  lipoma,  or  a  sarcoma  of  the  cranium, 
infiltration  of  the  epicranium  induces  complete  anesthesia. 
The  illustration  shows  a  lozenge-shaped  injection  circumscrib- 
ing the  tumor  through  dermal  wheals  in  accordance  with  the 
direction  of  the  arrows. 


A  simple  circular   injection  under   the   skin   suffices 
for  trephining  and  operations  on  the  brain. 

Where  muscles,  however,  cover  the  cranial 
bones  at  the  line  of  injection,  they  must  be  in- 
jected. A  band  of  infiltration,  starting  in  front 
from  the  eyelids,  extending  to  the  occiput,  and 
passing  above  the  arch  of  the  ear,  will  desensi- 
tize the  entire  cranium  above  this  line.     It  is  not 


CRANIAL   OPERATIONS. 


39 


necessary  to  make  a  subperiosteal  injection.  The 
band  of  anesthesia  just  mentioned  possesses  an- 
other advantage:  The  cranial  arteries  ascend, 
like  the  nerves,  spreading  out  toward  the  summit 
under   the    epicranium    or,    as    in    the    case    of    the 


Fig.  21. — Craniectomy  for  sarcoma.  (Braun.)  The  frontal 
portion  of  the  infiltration  is  designed  to  abolish  sensibility  of 
the  anastomoses  between  the  frontal  and  parietal  nerves. 


temporal  arteries,  in  the  muscles.  Adrenin  con- 
tracts them,  rendering  the  operative  field  relatively 
bloodless,  and  the  various  methods  for  arresting 
hemorrhage  superfluous.  At  times  the  large  ar- 
teries bleed  a  little  and  must  be  clamped;  the 
small  arteries  do  not  bleed.  For  small  fields  of  op- 
eration a  jA  per  cent,  solution  suffices;  for  large 
fields,  rich  in  vessels,  a  i  per  cent,  will  yield  a, 
Ijctter    hemostasis. 


40 


REGIONAL   ANESTHESIA. 


Starting  from  two  wheals  which  correspond,  re- 
spectively, to  the  extremities  of  the  intended  incision, 
one  injects  in  a  lozenge  or  quadrilateral  form  lo 
to  20  mils  of  a  ^  per  cent,  solution  (Figs.  20, 
21,   22). 


Fig.  22. — Anesthesia  for  trephining.  (Pauchet.)  Observe 
the  crucial  incision.  A,  the  wound.  B,  dermal  wheals.  P,  a 
zone  of  infiltration  1  centimeter  in  width  surrounding  the 
wound,  as  shown  by  the  dotted  line  down  to  the  bone.  This 
yields   perfect   anesthesia   and    ischemia. 


Treatment  of  Large  Wounds  in  the  Soft 

Tissues,  or  of  Compound  Fractures, 

OF  the  Skull. 

Several  wheals  are  made  around  the  wound — 
as  in  Fig.  23,  in  which  there  are  seven — suffi- 
ciently close  together  for  the  curvature  of  the  skull 
to   permit   of   the   needle   going  under   the   epicran- 


CRANIAL   OPERATIONS. 


41 


ium.  With  a  i  per  cent,  solution,  a  narrow  band 
of  infiltration,  circumscribing  the  field  of  operation 
according  to  the  line  indicated,  is  now  traced  in 
the  soft,  subaponeurotic  tissues.  Along  a  distance 
of  5  centimeters,  about  5  mils  of  solution  should 
be  injected. 


Fig.  23. — Anesthesia  of  the  epicranium  around  a  wound 
(Pauchet.)  This  can  be  practised  in  all  operations  upon  the 
cranium  for  war  wounds  (bone  and  soft  tissues)  through  as 
many  dermal  wheals  as  may  be  necessary  to  surround  com- 
pletely the  territory  with  a  zone  of  infiltration,  made  with,  a 
1  per  cent,  solution. 


The  peripheral  line  of  injection  should  be  far 
enough  removed  from  the  wound  to  permit  of  all 
necessary  excision  or  enlargement  for  perfect  re- 
pair, for  any  pedicle  required  or  for  a  dissection 
necessary  for  plastic  repair.  Only  a  few  moments 
are  required   for  complete  anesthesia. 

In  their  ambulance  on  the  western  fighting 
front,    in    September,    19 14,    Pauchet  and    Laboure 


42  REGIONAL   ANESTHESIA. 

trephined  a  case  for  hemiplegia,  under  local  anes- 
thesia, with  the  patient  in  the  sitting  position. 
After  the  completion  of  the  operation  the  patient 
walked  to  the  railway  station,  assisted  by  a  fel- 
low-soldier. 


Removal   of   Malignant   Tumors   of   the 
Cranium,    witli    Bone    Resection. 

The  surgeon  required  to  remove  a  tumor  ad- 
herent to  the  skull  should  at  the  same  time  re- 
move   the    skin    covering    the    tumor    and    a    rather 


Fig.  24. — Repair  of  a  craniectomy.  (Braun.)  Shows  a 
flap  to  be  re-applied  as  covering  to  the  bony  surface  excised. 
It  is  well  to  cover  the  opening  over  the  brain  with  a  layer  of 
fascia  lata  to  replace  the  dura  mater  and  prevent  adhesions  of 
the  skin  to  the  deeper  surfaces.  Skin  grafts  may  be  used  to 
cover  the  denuded  occipital  zone  when  new  tissue  has  grown 
over  the  skull.  The  opening  in  the  skull  should  be  reinforced 
with  a  chondrocostal  piece  or  a  gold  plate.  All  this  may  be 
perfectly  done  under  local  anesthesia. 


CRANIAL   OPERATIONS.  43 

large  section  of  bone.  The  operation  will  be  pain- 
less, since  the  dura  mater,  together  with  all  the 
other  local  tissues,  are  insensitive.  The  anesthesia 
should  be  instituted  as  already  indicated,  viz.,  on 
a  line  extending  from  the  eyes  to  the  occipital 
protuberance,   the   line   of   the   hat   band. 

Equally  good  results  are  obtained  in  the  case 
of  a  sarcoma  originating  in  the  periosteum  and 
adhering  to  the  skin.  The  surgeon  is  enabled  to 
remove  painlessly  the  skin,  pericranium,  perios- 
teum, bone  tissues,  and  dura  mater.  The  brain 
surface  should  under  these  conditions  be  recovered 
with  skin.  The  liberation  of  an  area  of  skin  pos- 
teriorly for  this  purpose  may  likewise  be  effected 
without   pain. 

Trephining  the  Temporal  Region. 

Regional  anesthesia  permits  of  removal  of 
epidural  hematomas  of  the  inferior  meninges, 
craniectomy  for  decompression  (Babinski),  and  re- 
moval of  bone  fragments  and  foreign  bodies.  The 
dura  mater  near  the  base  of  the  cranium  is  sen- 
sitive,   but   only   moderately   so. 

Fig.  25  shows  how  to  place  the  wheals,  and 
the  form  of  the  injection,  for  the  dissection  of  a 
temporal   osteocutaneous   flap. 

One  is  in  the  middle  of  the  superior  border 
of  the  zygoma;  at  this  point  one  injects  subcuta- 
neously  a  ^^  or  i  per  cent,  solution.  There  is 
also  to  be  infiltrated  a  layer  of  temporal  muscle 
as   shown   in   the   diagrammatic   Fig.    26,   represent- 


44 


REGIONAL   ANESTHESIA. 


Fig.  25. — Trephining  the  temporal  region  for  decompression, 
(Pauchet.)  The  horse-shoe-shaped  flap  comprises  the  skin, 
the  temporal  muscle,  and  the  periosteum.  The  illustration 
shows  the  surrounding  band  of  anesthesia  induced  through  six 
dermal  wheals.  The  lower  side  of  the  pentagon,  wheals  1,  2, 
and  6,  should  be  infiltrated  down  to  the  bone  with  a  1  per 
cent,  solution  of  procaine-adrenin ;  the  other  sides,  with  a  J/2 
per  cent,  solution. 


iiiiiiiiii  ii\iuiiiiui  iriiinini  iiiiiinirnirniiiiiiiiriT 


Fig.  26. — Anesthesia  of  the  base  of  the  pentagon  (Fig.  25) 
for  trephining  the  temporal  region.  (Pauchet.)  The  fan- 
shaped  infiltration  follows  the  direction  of  the  arrows.  Ar- 
rows 1  and  2  pierce  the  temporal  muscle  and  reach  the  bone; 
arrow  3  infiltrates  the  subcutaneous  tissue. 


CRANIAL   OPERATIONS. 


45 


ing    a    horizontal    incision    parallel    to    the    superior 
border   of   the   zygoma   through   the   skin,   temporal 


Fig.  27. — Photograph  of  a  craniectomy  made  in  the  service 
of  Dr.  Rabinski.  (Pauchet.)  The  musculo-cutaneous  flap  is 
held  by  two  clamps ;  note  that  the  operation  is  practically 
bloodless  on  account  of  the  adrenin  contained  in  the  solution 
injected.     The  dura  mater  is  not  opened. 


muscle  and  temporal  bone.  The  needle  is  first 
introduced  through  wheal  i,  perpendicularly 
from    the    surface    down    to    the    bone    farrow    i) 


46  REGIONAL   ANESTHESIA. 

then  obliquely  toward  the  anterior  and  posterior 
margins  of  the  temporal  muscle,  again  down  to 
the  bone  (arrow  2)  and  following  a  horizontal 
plane,  and  finally  even  more  obliquely  in  the  sub- 
cutaneous tissue  (arrow  3),  from  2  to  6.  To  in- 
filtrate this  layer,  about  30  mils  is  required;  to 
circumscribe  the  field  of  operation,  about  30  mils 
more;  in  all,  about  60  mils  of  procaine-adrenin 
solution. 

Removal  of  the  Gasserian  ganglion  would  be 
practicable  by  this  method,  but  at  the  present  time 
injection  of  the  branches  of  the  5th  nerve  at  their 
emergence  from  the  ganglion,  and  their  destruc- 
tion  by   alcohol,    is   preferred. 

Exposure  of  the  Cerebellum. 

In  19 1 2  we  suggested  to  Thierry  de  Martel 
the  following  technique,  which  this  skillful  opera- 
tor was  the  first  to  apply  in  tumor  of  the  cere- 
bellum with  complete  success.  Fig.  28  shows  the 
situation  of  the  wheals  and  the  shape  of  the  in- 
cision for  exposing  the  cerebellar  hemispheres.  It 
is  best  not  to  depart  from  this  tracing,  even  if 
one  has  decided  not  to  touch  more  than  half  of 
the  cerebellum.  Points  3  and  9  are  placed  just 
behind  the  base  of  the  mastoid.  From  these  two 
points,  as  from  i,  2,  and  10,  the  necessary  injec- 
tions are  made  in  the  muscles  of  the  neck.  Next, 
the  muscular  layer  outlined  by  the  points  of  in- 
jection is  impregnated  with  a  solution  of  procaine- 
adrenin   along   the   line    shown.      In   the    flap    itself 


CRANIAL   OPERATIONS. 


47 


no  injection  is  made.  This  illustration,  taken  in 
conjunction  with  that  for  temporal  injection  (Fig. 
26),  defines  the  path  of  the  needle.  The  point 
should  penetrate  to  the  transverse  processes  of  the 
cervical  vertebrae  and  down  to  the  occiput.  Union 
of  the  successive   injections   by   subcutaneous   injec- 


Fig.  28. — Trephining  for  a  tumor  of  the  cerebellum. 
(Pauchet.)  The  10  dermal  wheals  in  the  form  of  a  trapezium 
surround  the  field  of  operation  with  a  zone  of  infiltration. 
The  proposed  flap  is  shown  by  the  dark  line  in  the  shape  of 
a  horse-shoe. 


tions  follows;  lOO  to  120  mils  of  solution  are 
used,  over  half  of  which  goes  into  the  muscles  of 
the  neck.  Thierry  de  Martel  operated  with  his 
patient  sitting  astride  a  chair,  with  the  arms  rest- 
ing on  its  back,  and  his  head  resting  on  his  arms. 
The  dura  mater  of  the  posterior  cerebral  fossse 
and  the   cerebellum   are   insensitive   to   pain. 


CHAPTER    IV. 

ANESTHESIA    OF    THE    HEAD    AND    NECK. 

The  surgery  of  the  head  and  the  neck  is  of 
interest  both  to  general  operators  and,  particu- 
larly, to  three  classes  of  specialists,  the  ophthal- 
mologist, the  otorhinolaryngologist,  and  the  stom- 
atologist. 

In  these  regions  the  sensory  supply  is  fur- 
nished by  the  fifth  nerve  and  the  cervical  plexus. 
The  fifth  nerve  is  predominant  in  the  face.  As 
several  branches  often  combine  in  supplying  sen- 
sation to  a  single  region,  it  is  sometimes  neces- 
sary in  these  tissues  to  combine  root  or  trunk 
anesthesia  with  peripheral  infiltration.  Or,  it  may 
be  necessary  to  combine  root  anesthesia  with  anes- 
thesia of  the  neighboring  regions. 

We  shall  first  consider  synthetically  the  subject 
of  anesthesia  of  the  nerve  roots  and  nerve  branches, 
and  then  describe  the  technique  for  each  operation 
involved    in    the    three    specialties    mentioned. 

Anesthesia  of  the  Gasserian   Ganglion. 

The  ganglion  of  the  fifth  nerve  is  intracranial. 
It  rests  upon  the  summit  of  the  petrous  portion 
of  the  temporal  bone  (Fig.  29)  in  a  fold  of  the 
dura  mater  just  above  and  behind  the  foramen 
ovale,  and  in  the  immediate  neighborhood  of  a 
(48) 


ANESTHESIA    OF   THE    HEAD   AND    NECK. 


49 


venous  sinus  and  of  the  motor  nerves  of  the  eye 
(fourth  and  sixth).  It  has  three  branches:  the 
ophthalmic,  the  superior  maxillary,  and  the  in- 
ferior maxillary.  The  ganglion  is  accessible  through 
the  foramen  ovale,  an  orifice  measuring  ^^  centi- 
meter by  2  or  3  millimeters.  This  foramen  is 
situated   on    the   floor    of    the    cranium    immediately 


Fig.  29. — The  ganglion  of  Gasser.  (Hirschfeld.)  It  rests 
upon  the  summit  of  the  petrous  portion  of  the  temporal  bone. 
From  above  downward  the  illustration  shows  the  origin  of 
the  ophthalmic  nerve  and  of  the  superior  and  inferior  maxil- 
lary nerves. 


behind  the  base  of  the  pterygoid  process.  It  cor- 
responds, for  the  superior  maxillary,  to  the  outer 
side  of  the  last  two  molars  in  the  sagittal  region. 
It  is  located  at  a  depth  of  45  millimeters  from 
the   zygoma. 

Indications  for  Gasserian  anesthesia  are  two  in 
number : 

A.  Surgical    operations    on    the    face. 


50 


REGIONAL   ANESTHESIA. 


B.  Alcoholization  of  the  nerve  to  combat  per- 
sistent   neuralgia    (Sicard). 

The  anesthetist  should  bear  in  mind  the  fol- 
lowing  precepts : 


Fig.  30. — Injection  of  the  Gasserian  ganglion  through  the 
foramen  ovale.  (Braun.)  (1)  The  needle  represented  by  the 
dotted  lines  is  introduced  3  centimeters  from  the  commissure 
of  the  lips,  in  the  direction  of  the  zygomatic  arch,  until  it 
reaches  the  subtemporal  region  between  the  two  maxillary 
bones.  (2)  The  black  line  needle  shows  the  shank  raised  and 
the  needle  directed  toward  the  zygomatic  tubercle.  Being  kept 
in  contact  with  the  bone,  it  reaches  the  foramen  ovale,  com- 
ing in  contact  with  the  fifth  nerve,  in  the  terminal  branches 
of  which  it  provokes  pain. 


(i)  Use  a  fine,  sharp,  fliexible,  but  strong 
needle. 

(2)  Inject   slowly. 

(3)  Employ  a  concentrated  solution  in  small 
quantities,  viz.,  i  to  2  mils  of  a  2  or  4  per  cent, 
solution  of  procaine-adrenin. 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


51 


In  spite  of  these  precautions,  vertigo,  vomiting 
and  even  symptoms  of  meningitis  are  sometimes 
observed.      These    post-anesthetic    disturbances    do 


Fig.  31. — Injection  of  the  Gasserian  ganglion  (Braun.) 
The  patient  should  sit  erect,  looking  directly  forward.  The 
surgeon  introduces  the  needle  through  the  cheek  3  centimeters 
from  the  labial  commissure,  so  directing  it  that  it  remains  in 
the  plane  of  the  subject's  pupil.  The  index  finger  of  the  left 
hand  is  introduced  into  the  patient's  mouth  to  make  certain 
that  the  needle  shall  not  pierce  the  mucous  membrane.  The 
needle  should  be  directed  between  the  inferior  maxillary  and 
the  tuberosity  of  the  superior  maxillary. 


not  detract  from  the  value  of  the  procedure  be- 
cause the  method  of  anesthesia  tmder  discussion  is 
employed  for  serious  operations  on  the  face,  or 
obstinate  neuralgia  of  the  fifth  nerve,  which  war- 
rant its  application. 


52 


REGIONAL   ANESTHESIA. 


Technique  of  the  Injection. — The  patient  may 
be  in  the  lying  or  sitting  position.  Injection  is 
easier  on  a  sitting  subject,  the  operator  standing 
or  sitting  in  front  of  the  patient.  A  needle  9 
centimeters  in  length  should  be   selected. 

The    landmarks    include    some,  that    are    appre- 


Fig.  32. — Injection  of  the  Gasserian  ganglion.  (Braun). 
The  same  manenver  as  in  the  preceding  illustration.  The  needle 
is  first  directed  at  the  middle  of  the  zygomatic  arch.  As  soon 
as  the  point  touches  the  bone  of  the  subtemporal  region,  the 
shank  is  raised  so  that  the  point  is  directed  at  the  zygomatic 
tubercle.  Being  then  pushed  forward  about  1  centimeter,  it 
will  penetrate  the   foramen  ovale. 


ciable  to  sight  or  palpation  and  others  which  are 
found  by  the  point  of  the  needle  as  it  is  introduced, 
(i)  When  the  subject  looks  straight  to  the 
front  the  pupil  of  the  eye  supplies  the  direction 
of  the  frontal  plane  in  which  the  needle  must  be 
directed. 

(2)  The   labial   fissure. 

(3)  The  second  upper  molar. 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


53 


(4)  The  ascending  ramus  of  the  inferior 
maxillary,  the  inner  surface  of  which  may  be  felt 
by    introducing    the    index    finger    into    the    mouth. 

(5)  The    tuberosity    of   the    superior    maxillary. 

(6)  The  bone  in  the  subtemporal  region;  the 
needle,   when   correctly  directed,   will   strike   against 


Fig.  33. — The  sensory  nerve  supply  of  the  face  and  neck. 
(Hirschfeld.)  (1)  Ophthahiiic.  (2)  Superior  maxillary.  (3) 
Inferior  maxillary.     (4)   Cervical  plexus   (anterior  branches). 

this    resistant    surface,    which    is    situated    in    front 
of   the   foramen   ovale. 

(7)  The  middle  of  the  zygomatic  arch  and  the 
tubercle  of  the  zygoma;  the  tubercle  indicates  the 
point  at  which  the  needle  must  be  directed  in 
order  to  enter  the  foramen;  the  middle  of  the 
arch  indicates  the  bony  region  anterior  to  the 
frjramen  against  which  the  needle  must  strike  be- 
fore  penetrating   the   foramen    (Figs.    30,    31,    32). 


54 


REGIONAL   ANESTHESIA. 


The  cheek  is  pierced  3  centimeters  beyond  the 
labial  fissure,  on  a  line  with  the  lobe  of  the  ear. 
The  needle  is  inserted  with  one  hand.  With  the 
index  finger  of  the  other  in  the  mouth,  the  second 


Yig.  34. — Removal  of  a  cancer  from  the  velum  palati  and 
left  tonsil  by  transverse  incision  of  the  cheek  and  resection  of 
the  ascending  ramus  of  the  inferior  maxillary  bone  after 
anesthesia  of  the  Gasserian  ganglion.  (Pauchet.)  The 
photograph  shovs^s  the  loosening  of  the  upper  fragment  of  the 
inferior  maxillary,  operated  upon  by  Pauchet  and  Sourdat. 

superior  molar  and  the  tuberosity  of  the  superior 
maxillary  are  located  within,  and  the  ascending 
ramus    of    the    mandible    without.      The    needle    is 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


55 


to  pass  in  the  interval  bounded  by  these  bones; 
the  finger  in  the  mouth  follows  the  needle  point 
under  the  mucous  membrane  and  prevents  it  from 
perforating   the    latter. 


Fig.  35. — The  wound  is  held  open  after  the  resection  of  the 
maxillary  has  been   completed.      (Pauchet.) 


One  next  aims  at  the  subtemporal  region  to 
strike  the  bony  surface  already  mentioned.  The 
needle  should  be  directed  somewhat  obliquely  in- 
ward, i.e.,  in  the  line  of  the  pupil  when  the  sub- 
ject is  looking  straight  ahead.  It  should  be  also 
slightly  oblique  upward,  i.e.,  should  virtually  pass 
through   the  middle  of  the  zygoma, — which  can  be 


56 


REGIONAL   ANESTHESIA. 


controlled  by  surveying  the  patient  in  profile.  Its 
point  should  be  behind  the  second  upper  molar. 
Thus  directed,  the  needle  enters  the  subtemporal 
region,  which  marks  the  end  of  the  first  stage  of 


Fig.  36. — The  tonsillar  space  is  tamponed  after  the  resec- 
tion of  a  part  of  the  pharynx  and  of  the  tongue.  The  borders 
of  the  incised  cheek  are  retracted,  showing  the  extent  of  the 
wound.  The  tongue  is  drawn  out  with  the  aid  of  a  cord  held 
by  the  assistant. 


the  injection.  Care  should  be  taken  to  do  all  this 
very  slowly,  in  order  not  to  blunt  the  point  of 
the  needle  by  contact  with  the  bone. 

Then  the  point  is  disengaged  and,  slightly 
raising  the  shank  but  still  remaining  in  the  plane 
of  the  pupil,   the  point  is   advanced  about   i    centi- 


ANESTHESIA    OF   THE    HEAD   AND    NECK.  57 

meter,  gliding  along  the  surface  of  the  subtem- 
poral bone.  In  profile  one  aims  this  time  for 
the  tubercle  of  the  zygoma.  Resistance  ceases  as 
the  needle  enters  the  foramen  ovale.  A  tense 
membrane  is  traversed  about  7  centimeters  be- 
neath the  skin.  When  the  patient  notices  radiat- 
ing pains  at  first  in  the  superior  maxillary  nerve, 
entrance  into  the  ganglion  is  indicated.  One 
should  then  inject  i  to  i^  mils  of  a  2  per  cent, 
procaine-adrenin,  very  slowly  and  gently  pushing 
the  needle   in  another   Yz    centimeter. 

By  the  same  route,  but  without  entering  the 
foramen  ovale,  one  may  reach  the  inferior  maxil- 
lary nerve  as  it  emerges  from  this  foramen  and 
limit  the  injection  to  it.  It  is  difficult  clearly  to 
describe  this  procedure  in  words,  and  we  have 
therefore  attempted  to  supplement  the  explanation 
and  more  fully  guide  the  operator  by  the  several 
appended  cuts. 

Anesthesia   of   the   Ophthalmic   Nerve, 

The  frontal,  internal  and  external  nasal,  and 
lachrymal  nerves  separate  from  the  origin  of  the 
ophthalmic  immediately  before  it  enters  the  orbit. 
The  ophthalmic  is  fan-shaped  and  is  situated  be- 
tween the  bony  plate  and  the  muscular  cone  of 
the  orbit;  the  injection  must,  therefore,  be  made 
between  these  two.  The  frontal  and  lachrymal 
nerves  are  situated  externally  and  emerge  through 
the  superior  orbital  fissure.  They  are  reached 
along  the  external   wall  of  the  orbit. 


58 


REGIONAL   ANESTHESIA. 


Fig.  ZT . — The  ophthalmic  nerve  and  its  branches.  (Testut.) 
(1)  Ophthalmic.  (2)  Nasal.  (3)  Lachrymal.  (4)  Frontal. 
(5)  External  nasal.     (6)   Internal  frontal.     (7)  Ethmoidal. 


Fig.  38. — Base  of  the  orbit.  (Testiit.)  Zinn's  ring,  where 
the  motor  muscles  of  the  eye  are  attached.  On  the  left  is 
seen  the  sphenoidal  fissure  in  the  center  of  Zinn's  ring.  The 
nasal  nerve  and  ophthalmic  vein  are  in  the  ring.  The  frontal, 
lachrymal,  and  pathetic  nerves  are  in  the  sphenoidal  fissure. 


ANESTHESIA    OF   THE   HEAD   AND    NECK.  59 

The  nasal  nerves  occupy  the  upper  internal 
angle  of  the  orbit,  and  are  infiltrated  at  that 
point. 

The  frontal  nerves  supply  sensation  to  a  tri- 
angular area  of  integument  with  its  base  cor- 
responding to   the   entire   frontal    region   above   the 


Fig.  39. — Supraorbital  branches  of  the  ophthalmic  nerve. 
(Hirschfeld.)  To  anesthetize  these  branches,  inject  parallel 
to  the  superior  border  of  the  orbit. 


root  of  the  nose  and  its  apex  at  the  scalp  (Fig. 
40).  They  also  sensitize  the  frontal  sinuses  and 
the  upper  eyelids.  The  nasal  nerves  supply  the 
frontal,  ethmoidal,  and  sphenoidal  sinuses,  the 
nasal    septum,    and    the    nasal    lobes. 

Injections  may  be  made   from  three  points,   ac- 
cording to   the  operation  required. 


60 


REGIONAL   ANESTHESIA. 


(a)  Frontal  Infiltration. — The  operator  injects 
under  the  skin  lo  mils  of  a  i  per  cent,  procaine- 
adrenin,  commencing  above  the  external  orbital 
-apophysis  and  ending  above  the  corresponding 
apophysis  on  the  opposite  side.  The  line  of  in- 
jection  is    shown   by   the   black   line   in   Fig.   40. 


Fig.  40. — Injections  along  the  black  line  anesthetize  the 
ophthalmic  branches  of  the  fifth  nerve  and  render  insensible 
a  triangular  area.      (Pauchet  and  Sourdat.) 


(b)  External  Orbital  Infiltration. — This  blocks 
the  frontal   and  lachrymal  nerves. 

The  needle  is  introduced  at  the  external  angle 
and  the  outer  wall  of  the  orbit  followed  with  its 
point.  At  a  depth  of  about  4^  centimeters  the 
needle   point   will    come    in   contact   with   bone,    the 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


61 


orbital  vault,  and  will  have  passed  into  the  exter- 
nal portion  of  the  sphenoidal  fissure,  where  are  sit- 
uated the  frontal  and  lachrymal  nerves.  Five  mils 
of  the  2  per  cent,  solution  are  now  injected,  and 
the  resulting  anesthesia  will  be  complete  (Figs. 
41,   42). 


Fig.  41. — Intraorbital  injections  for  infiltration  of  the 
ophthalmic  branches.  (Brauii.)  To  the  left,  an  external  in- 
jection, which  keeps  in  contact  with  the  external  orbital  wall. 
At  a  depth  of  4  centimeters  the  needle  point  strikes  the  orbital 
vault.  It  now  crosses  the  extremity  of  the  sphenoidal  fissure, 
along  which  pass  the  lachrymal  and  nasal  nerves.  A  1  per 
cent,  solution  of  procaine-adrenin  is  injected. 

To  the  right,  an  internal  injection.  The  needle  follows 
the  superointernal  angle  of  the  orbit,  constantly  in  contact  with 
the  bone  and  grazing  the  ethmoidal  foramen.  At  a  depth  of  4 
centimeters  it  comes  in  contact  with  the  orbital  vault.  The 
solution  is  injected  while  the  needle  is  being  introduced. 


(c)  Infernal  Orbital  Infiltration, — At  an  equal 
distance  from  the  eyebrow  and  the  caruncle,  i.e., 
I  centimeter  above  the  internal  commissure  of  the 
eyelids,  the  needle  is  introduced  against  the  supe- 
rior internal  angle  of  the  bony  wall,  which  should 


62 


REGIONAL   ANESTHESIA. 


be  continuously  followed.  At  a  depth  of  4  or  at 
most  45^  centimeters,  5  mils  of  a  2  per  cent,  solu- 
tion are  injected    (Figs.   41,  42). 

This  last  injection  anesthetizes  the  nasal  wall 
and  the  ethmoidal,  sphenoidal,  and  frontal  sinuses, 
as    well    as    the    lobe    of    the    nose.       It    induces 


Fig.  42. — Anesthesia  of  the  ophthahnic  branches  by  the 
orbital  route:  (1)  External.  (2)  Internal.  (Pauchet.)  The 
dotted  line  shows  the  shape  and  extent  of  the  orbital  orifice. 
Needle  1  is  entered  at  the  extreme  angle  of  the  commis- 
sure of  the  eyelids.  It  follows  the  bony  wall  and  stops  only 
when  it  comes  in  contact  with  the  orbital  vault,  where  it  crosses 
the  sphenoidal  fissure  (see  Fig.  41).  Needle  2  is  entered  at 
the  superior  internal  border  of  the  orbit,  one  finger  breadth 
above  the  caruncle.  The  point  is  kept  in  constant  contact  with 
(the  superior  internal  angle  of  the  bony  wall  to  reach  the 
ethmoid  nerves. 


edema  of  the  upper  lid,  causes  projection  of  the 
eye-ball,  and  sometimes  results  in  blindness  for  a 
few  minutes.     The  optic  nerve  is  not  anesthetized. 


ANESTHESIA    OF   THE    HEAD   AND    NECK. 


63 


Anesthesia  of  the  Superior  Maxillary  Nerve. 

The  superior  maxillary  passes  through  the 
foramen  rotundum  at  the  bottom  of  the  pterygo- 
maxillary   fissure,    precisely  between   the    tuberosity 


Fig.  43. — Injection  of  the  superior  maxillary  at  the  fora- 
men rotundum  by  the  external  route,  {braun.)  The  needle  is 
introduced  at  the  intersection  of  a  vertical  line  drawn  down- 
ward following  the  external  border  of  the  orbit  and  a  line 
drawn  along  the  inferior  border  of  the  superior  maxillary  bone 
(dotted  lines). 


of    the    superior    maxillary    and    the    base    of    the 
pterygoid  process. 

{a)  External  Route  (Figs.  43,  44). — Locate 
the  zygomatic  arch  with  the  finger;  mark  its 
lower  border  with  ink;  mark  the  external  border 
of  the  orbit  in  the  same  manner  at  the  point 
where    a    vertical    line    drawn    from    this    external 


"64 


REGIONAL   ANESTHESIA. 


border  meets  the  zygomatic  arch  (just  behind  the 
lower  angle  of  the  body  of  the  malar  bone),  and 
introduce  the  needle  to  a  depth  of  5  to  6  centi- 
meters. In  this  way  the  nerve  is  reached  at  once; 
but  it  is  preferable  to  attain  first,  with  the  point 
of  the  needle,  the  body  of  the  maxillary  on  its 
inclined  surface,  feeling  one's  way,  and  directing 
the  needle  deeply.      Suddenly   the  needle  will   come 


Fig.  44. — The  needle  is  first  directed  toward  the  tuberosity 
of  the  maxillary  bone,  whence  it  penetrates  directly  about  4 
centimeters  and  enters  the  pterygo-maxillary  fissure.  (Braun.) 
When  the  patient  complains  of  a  shooting  pain  in  the  teeth, 
from  3  to  4  mils  of  a  2  per  cent,  anesthetic  solution  are  injected. 


to  an  empty  space  and  touch  the  nerve,  when  the 
patient  will  experience  a  sharp  pain  in  the  face 
and  upper  teeth.  Five  mils  of  a  2  per  cent,  pro- 
caine-adrenin  solution  are  now  injected,  and  while 
withdrawing  the  needle,  5  mils  of  a  }^  per  cent, 
solution.  To  cause  the  branches  of  the  internal 
maxillary  to  contract,  it  is  often  necessary  to  have 
the  patient  open  his  mouth,  when  the  needle  will 
enter  more  easily    (Fig.   45). 


ANESTHESIA    OF   THE    HEAD   AND   NECK. 


65 


Fig.  45. — Anesthesia  of  the  superior  and  inferior  maxillary 
through  the  same  orifice.  (Pauchet.)  The  patient  is  made  to 
open  his  mouth.  The  needle  is  introduced  below  the  zygo- 
matic arch  and  introduced  as  far  as  the  pterygoid  process,  then 
partly  withdrawn  and  the  point  directed  slightly  forward  to 
reach  the  pterygo-maxillary  fissure,  where  it  encounters  the 
superior  maxillary  nerve  at  the  foramen  rotundum.  Again  the 
needle  is  partly  withdrawn  and  then  reinserted  about  1  centi- 
meter further  back,  where  it  reaches  the  foramen  ovale  be- 
hind the  root  of  the  pterygoid  process.  The  foramen  ovale 
is  at  a  depth  of  about  4  to  5  centimeters. 


66  REGIONAL   ANESTHESIA. 

(b)  Orbital  Route  (Figs.  46,  47). — At  the 
junction  of  the  external,  lateral,  and  inferior  bor- 
ders of  the  orbit,  a  dermal  wheal  is  made  and  the 


Fig.  46. — Anesthesia  of  the  left  superior  maxillary  nerve 
at  the  foramen  rotundum  by  the  orbital  route.  (Braun.)  The 
needle,  which  at  first  is  held  vertically  (Fig.  47),  comes  in 
contact  with  the  floor  of  the  orbit  on  a  level  with  its  in- 
ferior external  angle.  Entering  deeper,  it  reaches  a  space  on 
a  level  with  the  orbital  fissure.  Thence  it  progresses  back- 
ward ahnost  horizontally,  following  the  direction  of  the  fis- 
sure. At  a  depth  of  about  5  centimeters  it  reaches  the  base 
of  the  cranium  and  the  foramen  rotundum.  One  to  2  mils  of 
a  2  per  cent,  anesthetic  solution  are  injected. 


point  of  the  needle  then  introduced  almost  ver- 
tically downward.  In  order  that  it  shall  pass 
along  the  floor  of  the  orbit,   it   should  be  directed 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


67 


slightly  backward.  At  a  depth  of  about  i  centi- 
meter it  will  traverse  a  fibrous  layer — the  fissure 
of  the  orbital  floor.  As  soon  as  the  needle  reaches 
this  space  its  flange  end  should  be  lowered  so  as 
to    bring    it    almost    horizontal,    while    the    head    of 


Fig.  47. — This  figure  shows  the  manner  in  which  the  needle 
point  is  made  to  follow  the  floor  of  the  orbit.  By  placing  a 
rubber  shield  upon  the  needle,  the  surgeon  can  make  the  lat- 
ter serve  as  an  index  of  depth  in  the  procedure  described  in 
Fig.  46.     (Braun.) 


the  patient  is  held  quite  erect.  If  the  needle  is  not 
horizontal,  it  will  enter  the  subtemporal  space. 
Yet  it  should  not  be  introduced  too  high  up,  or 
it  will  enter  the  eyeball.  It  should  be  directed  in 
the  jjlane  of  the  fissure,  i.e.,  in  the  direction  of 
the    inferior,    external    angle.      One    should    always 


68 


REGIONAL    ANESTHESIA. 


feel  a  certain  resistance  at  this  point.  At  a  depth 
of  5  centimeters,  the  situation  of  the  needle  will 
correspond  to  the  foramen  rotundum.  At  this 
point  it  will  come  in  contact  with  the  base  of  the 
skull.     Five  mils  of  a  2  per  cent,   solution  of  neo- 


Yig.  48. — Emergence  of  the  infraorbital  nerve.  (Hirsch- 
feld.)  On  the  same  vertical  line  as  the  supraorbital  nerve,  it 
is  situated  Yz  centimeter  below  the  middle  of  the  lower  bolder 
of  the  orbital  foramen. 


caine-adrenin  are  now  injected.  At  times  a  tem- 
porary paralysis  of  the  muscles  of  the  eye,  or  a 
hematoma  in  the  pterygomaxillary  fissure,  will  ap- 
pear. Both  these  conditions  are  incidents  devoid 
of  serious  consequences. 


ANESTHESIA    OF   THE    HEAD   AND    NECK.  69 

Anesthesia   of   the   Infraorbital   Nerve. 

The  infraorbital  nerve,  a  branch  of  the  supe- 
rior maxillary,  is  accessible  through  the  cheek. 
The  lower  border  of  the  orbit  is  marked  with  a 
dermal  pencil,  a  line  drawn  from  the  center  down- 
ward ^  centimeter,  and  a  cross  made.  This 
corresponds  to  the  point  of  emergence  of  the  in- 
fraorbital nerve.  The  three  apertures  whence  the 
infraorbital  and  mental  nerves  arise  are  on  the 
same  vertical  line,  and  correspond  to  the  interval 
between  the  first  and  second  premolars  (Fig.  45). 
A  dermal  wheal  is  made,  and  the  subcutaneous 
cellular  tissues  infiltrated  so  that  contact  will  not 
be  painful.  Then,  with  the  needle,  the  infraorbital 
opening  is  found.  Coming  in  contact  with  the 
bone,  the  operator  feels  around  while  directing  the 
needle  a  little  higher  and  outward;  soon  he  be- 
comes aware  of  a  small  depression  and  penetrates 
into  a  canal.  The  patient  feels  a  sharp  pain. 
One  mil  of  a  2  per  cent,  solution  is  now  injected. 
The  anesthesia  thus  induced  extends  to  the  lower 
lid,  the  upper  lip,  the  nasal  ala,  a  part  of  the 
skin  and  mucous  membrane  of  the  cheek,  the  mu- 
cous membrane  of  the  lips,  the  margins  of  the 
superior  alveolar  process,  as  well  as  the  inferior 
walls  of  the  superior  maxillary  and  the  incisor 
and  canine  teeth. 


70  regional  anesthesia. 

Anesthesia  of  the   Superior  Dental 
Nerves. 

(a)  Buccal  Route. — The  zygomatic  arch  is 
located  through  the  mouth.  When  its  most  ante- 
rior point  is  feh,  the  mucous  membrane  is  pierced 
and  the  needle  introduced  for  a  distance  of  i  or 
2  centimeters.  The  patient  will  usually  feel  pain 
in  his  teeth.  Five  mils  of  a  2  per  cent,  procaine- 
adrenin   solution   are   now   injected. 

(b)  External  Route. — The  zygomatic  arch  is 
located  and  the  same  route  followed  as  that  taken 
to  reach  the  superior  maxillary  nerve.  As  soon 
as  the  tuberosity  of  the  superior  maxillary  is  at- 
tained, 5  mils  of  solution  are  injected.  This  in- 
jection anesthetizes  the  upper  molars  and  pre- 
molars as  well  as  the  mucous  membrane  of  the 
maxillary   sinus    (Fig.   29). 

Anestliesia  of  the  Nerves  of  the  Palate. 

The  inferior  palatine  nerve  emerges  from  the 
posterior  palatine  canal  above  the  last  molar.  The 
nasopalatine  nerve  arises  in  the  anterior  palatine 
canal,  in  the  median  line  and  behind  the  incisors. 
The  needle  is  introduced  anteriorly,  under  the 
mucous  membrane  of  the  palate,  immediately  be- 
hind the  teeth  and  in  the  median  line.  One  mil 
of  a  2  per  cent,  procaine-adrenin  solution  is  in- 
jected. Then,  behind  the  palate,  i  to  i}^  centi- 
meters within  the  second  molar,  or  rather,  within 
the  border  of  the  gums,  2  mils  of  the  solution 
are    introduced.      This    type    of    anesthesia,    carried 


ANESTHESIA    OF   THE   HEAD   AND    NECK. 


71 


Fig.  49. — To  the  right  are  shown  the  three  palatine  nerves 
descending  toward  the  posterior  palatine  foramen.  To  the 
left,  at  the  base  of  the  nose,  is  the  ethmoidal  branch  of  the 
internal   nasal  nerve. 


Fig.  50. — Anesthesia  of  the  hard  palate.  (Pauchet.)  In 
front  is  the  nasopalatine  nerve,  ^  centimeter  behind  the 
middle  incisors.  The  surgeon  injects  1  mil  of  a  2  per  cent, 
solution  directly  under  the  mucous  membrane.  Behind,  the 
nerves  emerging  from  the  posterior  foramen  to  the  right  and 
left,  1  centimeter  within  and  above  the  last  molar,  1  mil  of 
the  strong  solution  is  injected  beneath  the  mucous  membrane. 


72  REGIONAL   ANESTHESIA. 

out  also  on  the  opposite  side,  permits  the  surgeon, 
with  the  three  points  of  infiltration,  to  operate  on 
the  mucous  membrane  of  the  hard  palate  and 
periosteum,   though   not   on   the   teeth. 

•  Anesthesia  of  the  Buccal  Nerve. 

This  nerve  rests  upon  the  tuberosity  of  the 
superior  maxillary  and  is  distributed  over  the  mu- 
cous membrane  of  the  cheek.  It  is  accessible,  like 
the  superior  dental  nerve,  by  an  injection  passing 
along  the  tuberosity  and  following  a  vertical  line 
running  from  the  last  upper  molar  to  the  last 
lower   molar. 

Anesthesia   of   the    Inferior    Maxillary 
Nerve. 

As  already  pointed  out,  the  trunk  of  the  in- 
ferior maxillary  nerve  is  accessible,  at  its  emerg- 
ence from  the  foramen  ovale,  by  the  same  route 
and  with  the  same  procedure  as  was  described 
for  infiltration  of  the  Gasserian  ganglion.  To 
limit  the  injection  to  this  trunk,  it  is  sufficient  to 
make  the  injection  upon  arriving  at  but  not  enter- 
ing the  foramen  ovale.  The  advance  of  the  needle 
should  be  arrested  as  soon  as  the  resistance  of 
the  bone  ceases,  indicating  that  the  anterior  bor- 
der of  the  aperture  has  been  passed. 

The  following  mode  of  procedure  reaches  the 
nerve  without  risk  of  penetrating  too  far,  and 
the  operator  should  be  as  familiar  with  it  as  with 


ANESTHESIA    OF   THE    HEAD   AND    NECK. 


71 


the  method  first  described,  as  certain  conditions 
may  render  it  preferable,  e.g.,  anatomical  deformi- 
ties,  tumors,   etc. 

The    lower    border    of    the    zygomatic    arch    is 
traced    on    the    skin,    its    exact    center    found,    and 


Fig.  51. — Anesthesia  of  the  inferior  maxillary  nerve. 
(Braun.)  The  operator  places  a  small  fragment  of  cork  upon 
the  needle,  as  an  index.  The  needle  is  introduced  just  below 
the  center  of  the  zygomatic  arch.  At  a  depth  of  4  centimeters 
the  point  touches  the  pterygoid  process.  With  the  needle  held 
firmly  in  position,  the  cork  is  slid  down  to  a  level  with  the 
skin.  The  needle  is  then  partly  withdrawn  and  reintroduced 
at  an  angle,  so  as  to  touch  a  point  1  centimeter  behind  the 
point  first  reached.  When  the  index  cork  touches  the  skin,  the 
point  of  the  needle  is  near  the  foramen  ovale  and  when  it 
comes  in  contact  with  the  nerve  the  patient  feels  a  sharp  pain 
in  the  lower  jaw.  Two  mils  of  a  2  per  cent,  solution  of  pro- 
caine-adrenin  are  then  injected. 


a  dermal  wheal  made  at  this  point.  A  needle 
6  centimeters  long  is  now  introduced  transversely 
to  a  depth  of  4  to  5  centimeters  so  that  its  point 
will  strike  against  the  pterygoid  process,  which  is 
I  centimeter  from  the  foramen  ovale.  As  a  guide 
a  thread  or  small  piece  of  rubber,  passed  over  the 


74  REGIONAL   ANESTHESIA. 

needle  before  its  introduction,  is  now  fastened  pre- 
cisely at  a  level  with  the  skin.  The  needle  is  then 
drawn  toward  the  operator,  though  not  withdrazun 
altogether,  and  re-inserted  to  the  depth  marked  on 
the  needle,  aiming,  however,  about  i  centimeter 
behind  the  bony  obstruction  (pterygoid).  The 
earlier    and   later    directions    of   the    needle    should 


Fig.  52. — Direct  injection  of  the  inferior  maxillary  at  the 
foramen  ovale.  (Braun.)  The  needle  is  introduced  at  the 
junction  of  the  middle  and  posterior  thirds  of  the  zygomatic 
arch  and  directed  inward  about  5  centimeters,  when  it  will 
reach  the  foramen  ovale.  If  it  strikes  bone,  the  latter  is  the 
pterygoid  process ;  it  should  then  be  withdrawn  a  few  centi- 
meters and  reintroduced  further  back.  The  foramen  ovale  is 
located  immediately  behind  the  pterygoid  process. 

form  between  them  an  angle  of  30°.  As  soon  as 
the  needle  has  reached  the  same  depth,  though 
somewhat  posteriorly,  it  is  pushed  a  few  milli- 
meters further  in,  and  the  patient  will  feel  a 
sharp  pain  in  the  tongue  or  the  inferior  maxillary. 
This  indicates  that  the  needle  is  in  the  body  of 
the  nerve  (Figs.  51,  52).  Five  mils  of  a  2  per 
cent,  procaine-adrenin  solution  are  now  injected. 
(See   also   Oflferhaus's   procedure,   p.   98.) 


ANESTHESIA   OF   THE   HEAD   AND    NECK. 


75 


Anesthesia  of  the  Inferior  Dental 
Nerve 

This  is  a  large  terminal  branch  of  the  inferior 
maxillary.  It  diverges  at  an  acute  angle  from 
the   lingual   nerve   and  passes   between   the   internal 


Fig.  53. — Injection  of  the  inferior  dental  nerve  at  the  in- 
ferior dental  foramen.  (Braun.)  The  arrow  indicates  the 
point  at  which  the  nerve  should  be  injected.  The  dotted  ar- 
row shows  the  retromolar  trigone.  The  needle  should  be  first 
directed  to  this  trigone  1  centimeter  above  the  molar,  then 
should  follow  the  inner  wall  of  the  maxillary  bone  until  its 
point  reaches  the  nerve.  One  to  2  mils  of  a  2  per  cent,  solu- 
tion  are  then  injected. 


pterygoid  muscle  and  the  ascending  ramus  of  the 
inferior  maxillary  bone  until,  arriving  at  the  pos- 
terior orifice  of  the  dental  canal,  it  emerges  on  a 
level   with   the   chin  through   the  mental   foramen. 

Upon     examination     of     an     inferior     maxillary 
bone,   there   will   be   found   immediately   behind   the 


76 


REGIONAL   ANESTHESIA. 


last  molar  a  triangular  bony  surface,  limited  ex- 
ternally by  a  prolongation  of  the  coronoid  process 
and  within  by  a  ridge  of  bone  which,  likewise  de- 
tached from  the  process,  passes  down  toward  the 
inner    side    of    the    alveolus    of    the    third    molar. 


Fig.  54. — Shows  the  movements  imparted  to  the  needle  to 
reach  the  inferior  dental  foramen.  (Paiicliet.)  The  lingual 
nerve  may  be  reached  in  the  same  way. 


This  small  triangle  which  is  normally  covered  with 
mucous  membrane,  serves  as  the  principal  land- 
mark in  the   introduction  of  the  needle. 

The  patient  is  seated  in  front  of  the  operator, 
with  his  mouth  wide  open.  The  index  finger  is 
passed  into  the  mouth,  the  anterior  border  of  the 
coronoid   found,   and   within   this   border   the   retro- 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


77 


molar  trigone  (Braun)  located.  A  needle  9  centi- 
meters long  is  taken  in  the  right  hand,  and  being 
kept   I    centimeter   from  the   inferior   canine  on   the 


Fig.  55. — First  position  of  the  needle  in  going  for  the  retro- 
molar  trigone.  (Pauchet.)  The  needle  should  at  first  be  kept 
in  contact  with  the  canine  tooth  of  the  opposite  side  until  the 
trigone  is  reached.  The  handle  of  the  syringe  is  then  swung 
to  the  opposite  side,  so  the  needle  is  on  a  line  with  the  teeth, 
and  pushed  along  the  border  of  the  bone  to  the  foramen. 


opposite  side,  on  a  level  with  the  grinding  surface 
of  the  teeth,  directed  toward  the  trigone,  i.e.,  the 
intra-buccal  fold  of  the  coronoid.  The  point  of 
the  needle  penetrates  the  mucous  membrane  i 
centimeter    above    and    outside    of    the    last    molar. 


78  REGIONAL    ANESTHESIA. 

As  soon  as  the  membrane  has  been  punctured  the 
point  strikes  against  bone;  if  not,  the  point  is  too 
far  within.  Then  the  operator,  feehng  his  way, 
inserts  the  point  of  the  needle  until  it  reaches  the 
ridge    of    the    bone     (Fig.     54).       It    should    slide 


Fig.  56. — Anesthesia  of  the  inferior  dental  and  lingual 
nerves  on  the  right  side.  (Pauchet.)  (1)  Right  inferior  den- 
tal nerve.  (2)  Right  lingual  nerve.  (3)  Left  inferior  canine. 
The  needle  is  directed  from  the  left  lower  canine  toward  the 
anterior  border  of  the  ascending  ramus  of  the  right  inferior 
maxillary  (Position  1).  It  is  then  directed  to  the  internal 
surface  and  introduced  to  a  depth  of  about  2  centimeters 
(Position  II). 

along  the  inner  surface  of  the  inferior  maxillary; 
then,  without  losing  its  contact  with  the  bone, 
penetrate  2  to  2j4  more  centimeters,  at  which 
point  the  operator  injects  5  mils  of  a  i  per  cent, 
solution  (Figs.  53,  55,  and  56). 


ANESTHESIA    OF    THE    HEAD    AND    NECK.  79 


Anesthesia    of    the    Mental    Nerve. 

On  a  vertical  line  passing  at  the  same  time 
the  supra-  and  infra-  orbital  nerves  and  corre- 
sponding to  the  space  between  the  two  first  lower 
molars,  is  to  be  found  the  mental  foramen  of  the 
inferior  maxillary.  This  is  situated  at  equal  dis- 
tances from  the  superior  and  inferior  borders  of 
the  jaw,  and  below  the  interval  between  the  first 
and  second  molars.  After  passing  through  the 
soft  tissues  to  this  point,  the  surgeon  injects  a  2 
per   cent,    solution   of   procaine-adrenin. 


Anesthesia   of   the    Lingual    Nerve. 

This  leaves  the  inferior  dental  nerve  and  branches 
off  to  the  tongue,  describing  a  curve  with  an 
antero-superior  concavity.  It  should  be  borne  in 
mind  that  this  nerve  is  in  the  lower  part  of  the 
tongue,  situated  very  superficially  beneath  the  mu- 
cous  membrane. 

The  procedure  is  therefore,  as  follows:  The 
tongue  is  held  in  a  compress  and  brought  for- 
ward toward  the  opposite  corner  of  the  mouth. 
A  line  of  anesthesia  4  centimeters  long  is  made  in 
the  groove  formed  by  the  tongue  and  gums,  with 
a    I    or   2   per    cent,    solution   of   procaine-adrenin. 

This  nerve  may  also  be  infiltrated  by  proceed- 
ing as   for  the   inferior   dental. 


$ 

80  .  REGIONAL   ANESTHESIA. 

Remarks. 

It  would  seem,  at  first  sight,  that  in  facial  op- 
erations, anesthesia  of  the  Gasserian  ganglion 
should  prove  all  sufficient.  Actually  this  is  not 
the  case.  In  the  first  place,  the  severity  of  the 
Gasserian  procedure  justifies  its  employment  only 
in  serious  interventions,  as  already  pointed  out. 
It  is  preferable,  therefore,  to  anesthetize  the  peri- 
pheral trunks.  Again,  there  exist  anastomoses 
with  the  cranial  nerves  or  with  branches  of  the 
cervical  plexus,  which  would  render  the  anesthesia 
incomplete  were  it  confined  to  a  single  nerve 
trunk. 

Indications  for  subcutaneous  peripheral  infiltra- 
tion, or  for  the  spraying  or  application  of  cocaine 
to  the  mucous  membranes,  therefore,  frequently 
exist.  These  various  procedures,  trunk  anesthesia, 
local  infiltration,  and  local  application,  are  of  mu- 
tual assistance  and  it  is  a  combination  of  the 
three  which  produces  a  practically  complete  anes- 
thesia. 

REGIONAL   ANESTHESIA    IN    RHINOLOGY. 

Submucous   Resection   of  the   Cartilage 
OF  THE  Nasal   Septum. 

Tampons  of  a  strong  solution  of  adrenin-co- 
caine  are  applied  for  lo  minutes.  A  2  per  cent, 
solution  of  procaine-adrenin  is  injected  under  the 
mucous  membrane  of  the  septum,  both  on  its  con- 
vex and  its  concave  surfaces.  One  should  in- 
filtrate   also,    especially    if    the    deviation    is    exten- 


ANESTHESIA   OF   THE   HEAD   AND    NECK. 


81 


sive,  the  three  nerve  trunks  which  together  sensi- 
tize the  septum,  above  and  forward,  below  and 
forward,   in  the  floor  and  behind. 


Hypertrophy  of  the  Lower  and  Middle 
Turbinates. 

Resection  of  the  Upper  and  Lower  Turbinates 
and  of  Nasal  Myxomas. — Tampons  of  cocaine 
which  contract  the  mucous  membrane  usually  suf- 


Fig.  57.— (1)  Ethmoidal  branch  of  the  internal  nasal  nerve. 
(2)  Nasopalatine  nerve  which  supplies  the  wall  and  emerges 
through  the  anterior  palatine  foramen,  behind  the  incisors. 
{Pauchet.) 

fice.  In  the  case  of  the  upper  turbinate,  however, 
their  use  is  disadvantageous  because  it  diminishes 
the  already  small  area  concerned.  It  is  prefer- 
able, therefore,  to  infiltrate  the  afi^ected  tissues,  as 
this  augments  their  volume.  In  the  presence  of 
numerous  polypi,  tamponing  is  tedious  and  some- 
times impossible.  We  therefore  inject  the  eth- 
moidal, nasal,  and  septal  nerves,  thus  rendering 
the  parts  anesthetic   (Fig.   57). 


82 


REGIONAL   ANESTHESIA. 


Moure's   Operation    for  Large   Tumors 
OF  THE  Brain. 

(a)   Application   of   cocaine   tampons   to   the   ol- 
factory  mucosa;    (b)    infiltration    of    the    ethmoidal 


Fig.  58. — Operation  of  Moure.  Resection  of  the  ethmoid 
after  having  displaced  downward  the  ascending  branch  of  the 
superior  maxillary  and  enlarged  the  anterior  orifice  of  the 
bones  of  the  nasal  fossa  without  regard  to  the  superior  maxil- 
lary. (A)  Infiltration  of  the  ethmoidal  nerve  by  the  internal 
orbital  route.  (B)  Infiltration  of  the  superior  maxillary  nerve 
(see  Figs.  43  and  44).  (C)  Emergence  of  the  infraorbital 
nerve. 


nerves;  (c)  infiltration  of  the  superior  maxillary 
nerve;  (d)  infiltration  of  the  infraorbital  nerve; 
(e)    infiltration   of   a   line   from   the   corner   of   the 


ANESTHESIA    OF   THE   HEAD   AND   NECK.  83 

mouth  Upward,  as  shown  in  Fig.  58.  Peripheral 
infiltration  following  a  broken  line  uniting  the 
corner  of  the  mouth  with  the  junction  of  the 
superior  maxillary  nerve  and  the  base  of  the  nasal 
lobe. 


Injection    of   the   Maxillary  Sinus 
(Luc's  Operation.) 

(a)    Tamponing    the    nasal    cavity  with    gauze 

soaked    with    cocaine;    (b)    infiltration  of    the    eth- 


Fig.  59. — Trephining  the  maxillary  sinus.  (Laboure.) 
(1)  Infiltration  of  the  superior  maxillary  nerve  at  the  foramen 
ovale  (Figs.  43  and  44).  (2)  Anesthesia  of  the  ethmoidal 
nerve  by  the  internal  orbital  route  (Fig.  41).  The  subcuta- 
neous infiltration  is  shown  by  the  dotted  lines. 


moidal  and  superior  maxillary  nerves;  (c)  infiltra- 
tion through  the  mouth  of  the  canine  fossa  and  the 
region  of  the  infraorbital  nerve   (Fig.   59). 


84 


REGIONAL   ANESTHESIA. 


Injection   of  the  Frontal  Sinus. 

(a)  Tamponing  the  anterior  superior  nasal 
fossa  with  gauze  soaked  with  cocaine;  (b)  infil- 
tration of  the  superior  maxillary  nerve;    (c)   infil- 


Figs.  60,  61. — Trephining  the  frontal  sinus,  one  side  and 
both  sides.  (Pauchet.)  (1)  Internal  orbital  injection  (Fig. 
41).  (2)  Point  of  injection  for  the  superior  maxillary  nerve 
(Figs.  43  and  44).  Through  the  several  dermal  v^rheals,  the 
field  of  operation  is  circumscribed  along  the  dotted  lines. 


tration  of  the  ethmoidal  nerves;  (d)  subcutaneous 
and  preperiosteal  injections  surrounding  the  opera- 
tive field   (Figs.  6o,  6i). 


ANESTHESIA   OF   THE   HEAD   AND   NECK.  85 

Operations  upon  the  Sphenoidal  Sinuses  and 
FOR   Sarcoma   of   the   Hypophysis. 

The  endonasal  route  is  followed;  submucous 
resection  of  the  cartilaginous  and  bony  septum; 
infiltration  of  both  sides  of  the  septum  and  of 
the  ethmoidal  nerves. 


REGIONAL  ANESTHESIA  IN  OTOLOGY. 
Nerve   Si^pply. 

The  middle  ear  receives  its  sensory  supply 
from  Jacobson's  nerve,  a  branch  of  the  glosso- 
pharyngeal,  and  the  superficial   petrosal  nerve. 

The  tympanum  and  external  auditory  canal  are 
supplied  by  two  nerves,  which  enter,  the  one  an- 
teriorly, the  other  posteriorly.  The  anterior  is 
the  auriculo-temporal  nerve,  a  branch  of  the  supe- 
rior maxillary,  which  supplies  the  antero-inferior 
floor  of  the  external  canal.  The  posterior  nerve 
is  the  auricular  branch  of  the  pneumogastric. 
These  nerves  enter  the  canal  at  the  union  of  its 
cartilaginous    and    osseous    portions. 

The  external  ear  is  supplied  by  the  great  auric- 
ular nerve,  the  auriculo-temporal,  the  lesser  occip- 
ital, and  the  auricular  branch  of  the  pneumogastric. 

The  nerve  supply  of  the  mastoid  region  con- 
sists of  the  sub-occipital  and  the  superior  cervical 
nerves,  through  branches   from  the  mastoid. 

All  of  these  nerve  branches  intercommunicate, 
and  practically  their  respective  limits  are  hard  to 
define. 


86 


REGIONAL   ANESTHESIA. 


Technique. 

Anesthesia  of  the  Middle  Ear  and  Tympanum. 
— In  the  middle  ear  the  nerves  are  superficial  and 
sub-mucous,  and  can  be  desensitized  with  Bonain's 
solution : 

!^  Cocaine  hydrochloride, 
Menthol, 

Phenol aa  1  grain. 

Adrenin .  0.001  grain. 


Fig.  62. — Anesthesia  of  the  auditory  canal.  (Laboure.) 
The  needle  is  introduced  at  the  junction  of  the  cartilage  and 
bone  on  the. superior  and  posterior  walls.  When  it  has  pene- 
trated 2  millimeters,  a  2  per  cent,  solution  is  injected. 


Upon  application  of  this  agent  one  may  pain- 
lessly curette  vegetations,  remove  a  polyp,  or 
puncture   the   tympanic   membrane. 

For  more  severe  procedures,  such  as  ossiculec- 
tomy, the  external  auditory  canal  is  anesthetized 
by  the  following  procedure   (Neumann)    (Fig.  62): 


ANESTHESIA    OF    THE    HEAD    AND    NECK.  87 

A  large  speculum  is  passed  into  the  canal  and 
inclined  backward  or  laterally,  thus  bringing  into 
view  the  point  of  junction  of  the  cartilage  with 
the  bone.  At  this  point,  above  and  behind,  at  the 
junction  of  superior  and  posterior  walls,  a  needle 
is  inserted  for  2  millimeters,  a  few  drops  of  solu- 
tion slowly  injected,  and  a  bony  contact  felt  for. 
The  bone,  when  reached,  should  be  followed  for 
some  distance  in  order  to  make  certain  of  inject- 
ing the  remainder  of  the  solution  into  the  sub- 
periosteal zone.  Such  an  injection  anesthetizes  the 
upper  portion  of  the  tympanum,  the  vestibule,  and 
the  ossicles.  One  should  wait  lo  minutes  before 
operating. 

The  injection  just  described  acts  in  the  fol- 
lowing manner:  On  a  level  with  Schrapnel's 
membrane,  the  two  epithelial  linings  meet,  the 
fibrous  tissue  of  the  tympanum  being  wanting.  An 
injection  of  fluid  following  the  epithelium  of  the 
canal  penetrates  under  the  epithelium  of  the  mid- 
dle ear  on  a  level  with  the  flaccid  membrane  and 
ascends  under  the  mucous  membrane  that  lines 
the  vestibule,  since  it  is  at  no  time  arrested  by 
any   barrier    (Molinar^). 

Anesthesia  of  the  External  Auditory  Canal. — 
The  external  auditory  canal  is  supplied  by  two 
nerves  which  penetrate  in  front  and  behind,  at 
the  union  of  the  cartilaginous  and  bony  portions 
of  the  canal.  They  can  be  reached  either  through 
the   canal  or  from  behind  the  auricle. 


1  Adolph  Molinar :    "Regional   Anesthesia   for  Operations  upon  the 
Auditory  Apparatus." 


88  REGIONAL   ANESTHESIA. 

The  needle  is  directed  backward  toward  the 
tympano-mastoid  fissure  in  the  direction  of  the 
pneumogastric.  Procaine-adrenin  solution  is  in- 
jected while  introducing  the  needle.  Then  the 
latter  is  withdrawn  i  centimeter,  without  entirely 
removing  it,  directed  downward,  forward,  and  in- 
ward   toward    the    condyle    of    the    maxillary,    and 


Fig.  63. — Showing  a  V-shaped  injection,  in  its 
relations  to  the  bony  parts. 


during  the  course  of  this  movement,  2  mils  of 
procaine-adrenin  solution  injected  to  a  depth  of 
not  more  than  2  centimeters.  After  this  pro- 
cedure, operations  for  furuncles  or  exostosis  in  the 
canal   can  be   satisfactorily   carried   out    (Fig.    63), 

Anesthesia  of  the  External  Ear  and  Mastoid 
Region. — Encircle  the  external  ear  and  mastoid 
region  with  a  series  of  injections  which  cross  each 
other  in  the  superficial  and  deep  tissues  (Fig.  64). 

It  is  useless  to  try  to  penetrate  beneath  the 
periosteum;   its   close   adhesion   renders   this   impos- 


ANESTHESIA   OF   THE   HEAD   AND   NECK.  89 

sible.  Besides,  such  a  procedure  would  be  un- 
necessary. The  bone  receives  its  nerve  supply 
from  without,  i.e.,  from  the  scalp.  The  operator 
may,  if  he  so  desires,  inject  along  the  line  of  the 
proposed  incision. 


Fig.  64. — Anesthesia  of  the  external  ear.  (Laboure.) 
Two  wheals,  superior  and  inferior,  are  made  and  injections 
executed  in  the  direction  of  the  arrows,  describing  a  diamond- 
shaped  figure  about  the  ear. 


These  various  forms  of  anesthesia,  viz.,  the  ap- 
plication of  Bonain's  mixture  to  the  tympanum  or 
vestibule;  infiltration  of  the  vestibule  through  the 
canal;  infiltration  of  the  auriculo-temporal  nerves 
and  the  auricular  branch  of  the  pneumogastric ; 
peripheral  anesthesia  around  the  external  ear  and 
mastoid,  constitute  a  series  of  procedures  neces- 
sary and  sufficient  for  a  number  of  different  oper- 


90 


REGIONAL  ANESTHESIA. 


Fig.  65. — Mastoidectomy.  (Laboure.)  A  subcutaneous 
polygon  is  infiltrated  through  four  wheals,  the  needle  enter- 
ing in  the  direction  of  the  arrows. 


o«.. 


Fig.  66. — Petromastoid  operation.  {Laboure.)  After  hav- 
ing infiltrated  as  in  Fig.  65,  three  more  wheals  are  made  and 
injections  executed  in  the  direction  of  the  two  arrows  {D) 
and  the  arrows  (£  and  F). 


ANESTHESIA   OF   THE   HEAD   AND   NECK.  91 

ations.  One  may  employ  one  procedure,  or  an- 
other, or  all  procedures  combined,  according  to  the 
case. 

In  general,  the  relative  indications  for  each 
may  be  stated  thus:  i.  For  perforation  of  the 
tympanum:  Application  of  Bonain's  mixture, 
which  drives  the  blood  from  the  tissues  and  indi- 
cates to  the  operator  the  area  anesthetized.  2. 
For  ossiculectomy:  Infiltration  of  the  superior 
wall  of  the  canal  and  vestibule,  and  application  of 
Bonain's  mixture.  3.  For  furuncle  of  the  canal: 
Infiltration  of  the  anterior  and  posterior  nerves  by 
an  injection  through  the  auriculo-mastoid  sulcus. 
4.  For  plastic  operations  on  the  external  ear: 
Peripheral  anesthesia  in  circular  form  instituted 
around  the  external  ear  as  a  center.  5.  For  mas- 
toiditis: As  in  the  preceding  (Figs.  65,  66).  6. 
For  curettage:  A  combination  of  all  the  preced- 
ing methods. 


REGIONAL  ANESTHESIA  IN  OPHTHALMOLOGY. 

Nerve   Supply. 

The  orbit  and  ocular  globe  receive  their  nerve 
supply  from  the  branches  of  the  ophthalmic.  In 
addition,  the  orbital  branch  of  the  superior  maxil- 
lary supplies,  through  its  terminal  trunks — the 
temporo-malar  nerves, — the  skin  of  the  temple,  of 
the  malar  region,  and  about  the  external  angle  of 
the  eye    (Figs.   37,   38,  39). 


92  REGIONAL   ANESTHESIA. 


Technique. 

Anesthesia  of  the  ophthalmic  nerve  and  its 
branches  may  be  obtained  by  external  and  internal 
orbital  injections,  the  technique  of  which  has  al- 
ready been  described  (Figs.  40,  41,  42,  with 
several  pages  describing  the  ophthalmic  and  its 
branches). 

If  necessary  the  anesthesia  may  be  completed 
by  infiltration  of  the  superior  maxillary  nerve  or 
of  a  few  of  its  branches,  as  already  described 
under  Anesthesia  of  the  Superior  Maxillary. 

For  completion  of  the  anesthesia  in  respect  of 
the  ciliary  nerves  or  the  ciliary  ganglion,  the  mus- 
cular pyramid  which  immediately  surrounds  the 
ocular  globe  should  be  infiltrated.  In  order  to 
effect  this,  one  should  direct  the  needle  toward  the 
vault  of  the  orbit,  keeping  as  close  as  possible  to 
the  outer  surface  of  the  eye-ball.  Five  mils  of  a 
I  per  cent,  procaine-adrenin  solution  are  injected, 
and  the  sub-conjunctival  tissue  also  infiltrated.  A 
needle  is  introduced  into  the  external  commissure 
of  the  eyelids,  and  pushed  down  between  the  con- 
junctiva and  the  bulb.  Then,  a  little  to  the  in- 
side, at  a  depth  of  4^  centimeters,  i.e.,  close  to 
the  ciliary  ganglion,  i  mil  of  a  2  per  cent,  solu- 
tion is  injected.  Finally  ^  mil  of  this  strong 
solution  is  injected  under  the  conjunctiva  sur- 
rounding the  bulb.  Thus,  whatever  be  the  oper- 
ation,—enucleation,  etc., — perfect  anesthesia  will  be 
obtained. 


ANESTHESIA    OF   THE    HEAD   AND    NECK. 


93 


Operations  on  the  Eyelids  and  Lachrymal 
Gland  (Fig.  67). — A  few  drops  of  cocaine  on  the 
conjunctiva,  together  with  an  injection  of  2  mils 
of  a  ^  per  cent,  solution  of  procaine-adrenin  near 
the  superior  bony  wall,  will  anesthetize  the  upper 
eyelid. 


Fig.  67. — Anesthesia  of  the  eyelids.     (Pauchet.)     One  injection 
through  a  wheal  sufifices   for  each  eyelid. 


For  the  lower  eyelid,  one  should  inject  2  mils 
along  the  inferior  orbital  wall,  in  a  fan-shaped 
area  2  centimeters  deep  and  2  across.  The  infra- 
orbital nerve,  and  the  anterior  ethmoidal,  which 
supplies  the  internal  portion  of  the  lower  eyelid, 
are    infiltrated. 

Cataract;  Iridectomy. — (a)  Drop  a  few  drops 
of  a   1/4  0   per   cent,    solution   onto   the   eyeball,   sev- 


94  REGIONAL   ANESTHESIA. 

eral  times,  as  it  will  then  act  by  absorption,  (b) 
Inject  ^  mil  of  ^  per  cent,  solution  procaine- 
adrenin  under  the  conjunctiva. 

Enucleation  of  the  Eyeball. — (a)  Inject  2  or  3 
mils  of  solution  through  the  external  superior 
angle,  (b)  Repeat  this  procedure  at  the  internal 
angle,  (c)  Infiltrate  the  superior  maxillary  nerve 
either  through  the  orbit  or  the  malar  region. 


REGIONAL  ANESTHESIA  IN  DENTAL  SURGERY. 
Nerve   Supply 

As  regards  the  upper  teeth,  the  nerves  first 
follow  above  the  outer  side  of  the  tuberosity  of 
the  superior  maxillary,  then  penetrate  it  in  order 
to  reach  the  dental  pulp.  Here  they  are  dis- 
tributed also  to  the  periosteum,  the  mucous  mem- 
brane, and  the  alveolar  tissue. 

The  lower  teeth  are  supplied  by  the  inferior 
dental  nerve,  which  enters  the  inferior  maxillary 
bone  at  the  inferior  dental  foramen  and  forms  the 
inferior  dental  plexus,  then  divides  into  two 
branches,  one  in  the  bone, — the  incisor,  which 
supplies  the  incisor  teeth, — the  other,  the  mental, 
which  supplies  the  chin  and  lower  lip.  The  lower 
gums  and  tongue  are  supplied  by  the  lingual 
nerve.  The  region  of  the 'incisors  is  supplied  b}^ 
branches  coming  from  the  inferior  dental,  mental, 
and   lingual   nerves,   all   more   or   less   inter-related. 


ANESTHESIA   OF   THE   HEAD   AND   NECK.  95 

Technique. 

Infiltration  of  the  Dental  Branches  in  the 
Upper  Jaw. — A  }4  per  cent  solution  is  used. 
From  2  to  lo  mils  suffices,  according  to  whether 
it  is  desired  to  anesthetize  one  tooth  or  an  entire 
half  of  the  jaw.  As  the  dental  branches  lie  super- 
ficially, immediately  under  the  mucous  membrane 
in  the  fold  of  the  gum.,  the  injection  is  readily 
carried  out  and  its  result  immediate.  The  point 
of  injection  varies  according  to  the  teeth  to  be 
rendered  anesthetic: 

{a)  For  the  incisors,  one  should  infiltrate  the 
submucous  membrane  in  the  median  line,  either  on 
the  level  of  the  frsenum  linguae  or  on  the  nasal 
floor  near  the  septum,  or  at  both  of  these  points. 

{b)  For  the  canine  and  first  molars,  the  injec- 
tion is  made   above  the  canine  tooth. 

(c)  For  the  large  molars,  one  infiltrates  well 
back  at  the  outer  border  of  the  tuberosity  of  the 
maxillary,  and  even  at  its  posterior  border  if  a 
curved  needle  is  available.  Again,  it  may  be 
considered  necessary  to  enter  through  the  cheek, 
to  a  depth  of  25^  centimeters,  in  the  direction  of 
the    superior    maxillary   nerve. 

To  permit  of  convenient  infiltration,  an  aid 
should  draw  aside  the  labial  commissures  with 
small   retractors. 

Where  the  work  bears  on  half  the  maxillary 
arch,  infiltration  should  be  carried  out  along  its 
entire   length. 


9^  ,  REGIONAL   ANESTHESIA. 

On  principle,  one  should  not  infiltrate  the  trunk 
of  the  superior  maxillary  nerve.  Yet  there  need 
be  no  hesitation  in  doing  so  in  cases  of  severe 
buccal   septicemia. 

Infiltration  of  the  Lower  Teeth. — Where  the 
incisors  and  canine  teeth  are  concerned,  one  may 
proceed  as  for  the  upper  jaw,  infiltrating  the  sub- 
mucous membrane  in  order  to  reach  the  ramifica- 
tions  of   the   mental   and   incisor   nerves. 

For  the  remaining  lower  teeth  this  procedure 
is  insufficient  because  the  inferior  dental  nerve 
lies  in  the  center  of  the  maxillary  bone,  which  is 
very  thick  at  this  point.  One  should,  therefore, 
infiltrate  the  trunk  of  the  nerve  at  the  dental 
foramen  as  already  described.  The  labial  commis- 
sure is  retracted,  the  ascending  branch  of  the  in- 
ferior maxillary  nerve  found,  and  3  to  5  mils  of 
a  y2  per  cent,  solution  of  procaine  injected  into  its 
center.      (Figs.  55  and  56.) 

If  the  buccal  cavity  is  too  septic,  the  inferior 
dental  nerve  can  be  anesthetized  from  the  outside; 
or  2  mils  of  anesthetic  solution  may  be  injected 
under  the  dental  collar  of  the  last  molars  in  order 
to  infiltrate  the  gingival  branches  of  the  buccina- 
tor— which,   however,   are   not   very   large. 

Unilateral  injections  under  the  gums  for  the 
lower  incisors  are  insufficient  because  of  the  anas- 
tomoses of  the  two  incisor  nerves.  To  obtain 
complete  insensibility,  both  nerves  must  be  infil- 
trated even  for  an  operation  involving  only  one 
side.      Two   mils   of   solution   are   injected   on   each 


ANESTHESIA    OF   THE   HEAD   AND   NECK. 


97 


side  of  the  median  line;  at  this  point  there  is 
a  slight  depression,  the  thin,  grooved  wall  of 
which   permits   of   absorption   of   the   procaine. 


REGIONAL  ANESTHESIA  OF  THE 
EACE  AND  JAWS. 

The    soft    tissues    of    the    face    are    supplied    by 
the  three  branches  of  the  trigeminus,  the  ramifica- 


Fig.  68. — The  sensory  areas  of  the  head.  (Testut.)  (1) 
Ophthalmic.  (2)  Superior  maxillary.  (3)  Inferior  maxil- 
lary. (4)  Cervical  plexus  (anterior  branches).  (5)  Cervical 
plexus    (posterior  branches). 


tions  of  which  are  so  intermingled  as  to  render 
trunk  infiltration  insufficient  for  complete  anesthe- 
sia. Even  infiltration  of  the  Gasserian  ganglion 
of  one  side  yields  only  an  incomplete  anesthesia 
when  the  operative  procedure  is  conducted  near 
the   median    line. 


98 


REGIONAL   ANESTHESIA. 


Fig.  69. — The  measurements  of  Offerhaus.  The  "tubercle 
line"  C  D  passes  a  few  millimeters  in  front  of  and  below  the 
foramen  ovale  at  points  A  and  B.  The  distance  E  F  from  one 
superior  dental  arch  to  the  other,  is  equal  to  A  B  from  one 
foramen  ovale  to  the  other.  Measuring  C  D  and  E  F,  sub- 
tracting the  latter  from  the  former,  and  dividing  the  result  by 
2  yields  the  distance  C  A  or  D  B.  This  procedure  constitutes 
an  alternative  method  for  injecting  the  superior  maxillary 
nerve  at  the  foramen  ovale.     (C/.  pp.  72-74.) 


Anesthesia   of   the   Midfrontal   Region. 

The  frontal  zone  is  supplied  by  branches  of  the 
ophthalmic  nerve, — lachrymal,  frontal,  and  nasal, — 
which  ascend  from  below.  It  is  sufficient,  there- 
fore, to  institute  a  horizontal  line  of  infiltration, 
both  intradermal  and  subperiosteal,  passing  above 
the   convexity  of  the   two   eyebrows    (Fig.   40). 


anesthesia  of  the  head  and  neck.         99 

Anesthesia  of  the   Nose,   Lips,  and   Cheeks. 

The  lobe  of  the  nose  is  easily  rendered  in- 
sensible by  means  of  a  circular  infiltration  outlin- 
ing its  base  (Figs.  70  and  71).  Thus,  in  the 
case  of  a  tumor  of  the  lobe  requiring  surgical  in- 
tervention, four  injections  should  be  made  through 


Fig.  70. — Circumscribing  the  lobe  of  the  nose.      (Braun.) 

dermal  wheals  located  as  follows:  One  on  the 
bridge  of  the  nose,  two  at  the  base  of  the  alse, 
and  the  fourth  at  the  base  of  the  nasal  septum  on 
the  upper  lip. 

The  upper  lip  (Fig.  71)  may  be  desensitized  by 
three  lines:  One  transversal,  going  from  the  base 
of  one  ala  to  the  other,  and  the  two  others  ver- 
tical, descending  from  the  extremities  of  the  pre- 
ceding  points    to    the    labial    commissures    and    also 


100 


REGIONAL   ANESTHESIA. 


ascending  to  meet  at  the  bridge  of  the  nose.  Two 
bands  of  infiltration  should  thus  be  made,  the  one 
subcutaneous,  the  other  submucous,  the  needle  be- 
ing directed  parallel  with  the  mucous  membrane 
by  means  of  a  gloved  finger  introduced  under  the 

lip. 


Fig.  71. — Anesthesia  of  the  lobe  of  the  nose  and  the  upper 
lip  through  two  wheals,  following  the  direction  of  the  arrows. 
(Pauchet.) 


Infiltration  of  the  upper  lip  may  usually  be 
combined  with  that  for  the  lobe  of  the  nose. 
The  anesthetized  area  may  be  enlarged  at  will  ac- 
cording to  the  necessities  of  the  operation  (as  in 
the   pentagon,    Fig.    72). 

For  harelip  one  should  infiltrate  a  band  ex- 
tending   from    the    commissure    of   the    lips    to    the 


ANESTHESIA   OF   THE    HEAD    AND    NECK. 


101 


infraorbital    foramen,    connected    by    a    transverse 
line   across   the   dorsum   nasi. 

The  anemia  produced  by  the  adrenin  facilitates 
operative  work.  The  tissues  are  not  altered  by 
peripheral    infiltration   made    at   a   distance. 


Fig.  72. — Anesthesia  for  facial  operations  (Pauchet.) 
There  are  two  median  wheals,  central  and  superior,  and  two 
lateral  and  inferior  wheals.  (5)  and  (6)  serve  for  anesthesia 
of  the  infraorbital  nerve.  (4)  applies  in  anesthesia  of  the 
ethmoidal  nerve.  The  dotted  polygon  is  a  line  of  infiltration 
made  with  a  1  per  cent,  solution. 


For  the  lower  lip  a  single  dermal  wheal  should 
be  made  on  the  chin,  and  from  this  point  two 
divergent  lines  of  infiltration  made  both  under  the 
skin  and  under  the  mucous  membrane,  with  the 
needle  guided  by  a  finger  introduced  in  the  mouth. 

The  chin  and  subjacent  symphysis  menti  some- 


102 


REGIONAL   ANESTHESIA. 


Fig.  72). — Median  section  of  the  body  of  the  inferior  maxil- 
lary. (Pauchet.)  The  anterior  and  posterior  sections  of  the 
body  of  the  maxillary  bone  are  infiltrated  through  three  wheals. 


Fig.  74. — Anesthesia  for  resection  of  the  superior  maxil- 
lary bone.  (1)  and  (la)  External  and  internal  orbital  injec- 
tions. (2)  Injection  of  the  superior  maxillary  nerve.  A  weak 
procaine-adrenin  solution  is  used  in  instituting  the  subcuta- 
neous bands  of  infiltration. 


ANESTHESIA    OF   THE    HEAD   AND   NECK. 


103 


Fig.  75. — Unilateral  resection  of  the  lower  jaw  (Pauchet.) 
The  inferior  dental  nerve  is  injected  at  the  inferior  dental 
foramen,  or  the  inferior  maxillary  nerve  at  the  foramen  ovale, 
and  the  subcutaneous  tissue  then  infiltrated  along  the  dotted 
line. 


Fig.  76. — Operation  on  the  horizontal  portion  of  the  lower 
maxillary  bone.  (Pauchet.)  The  inferior  dental  nerve  is 
anesthetized  at  the  inferior  dental  foramen  or  the  inferior 
maxillary  nerve  at  the  foramen  ovale,  and  a  subcutaneous 
diamond-shaped  figure  infiltrated  through  three  wheals.  The 
dark  line  indicates  the  incision. 


104  REGIONAL   ANESTHESIA. 

times  require  to  be  rendered  insensible,  e.g.,  for 
the  suture  of  a  fracture  of  the  mandible  (Fig,  73) : 

(i)  A  horse-shoe-shaped  band  of  infiltration 
following  the  lower  border  of  the  inferior  maxil- 
lary bone,  both  subcutaneous   and  subperiosteal. 

(2)  Infiltration  of  the  mental  nerve  on  one,  or 
better  both  sides,  even  if  the  operation  be  uni- 
lateral. 

Resection  of  the  Superior  Maxillary  (Fig.  74). 
— If  the  lesion  is  extensive  and  likely  to  cause  the 
surgeon  to  go  beyond  the  superior  maxillary,  he 
is  justified  in  infiltrating  the  Gasserian  ganglion, 
as  already  explained.  Generally,  however,  it  proves 
sufficient  to  proceed  thus :  ( i )  Infiltrate  the  supe- 
rior maxillary  nerve.  (2)  Infiltrate  the  inferior 
maxillary  nerve.  (3)  Infiltrate  the  orbital  nerves 
by  two  injections  in  the  superior-internal  and 
superior-external  angles.  (4)  Infiltrate  the  hard 
and  soft  palates,   following  the  line  of  incision. 

For  the  lower  jaw  (Figs.  75  and  76)  the  in- 
ferior maxillary  nerve  should  be  infiltrated  at  the 
foramen  ovale  or  .  at  the  dental  foramen  with  a 
j/2  per  cent,  solution  and  the  field  of  operation 
circumscribed  with  peripheral  injections  of  a  i 
per  cent,  solution.  One  can  then  operate  on  the 
bone  for  suturing  or  resection.  In  the  event  of 
cancer  at  the  alveolar  border,  the  nerves  should  be 
infiltrated  at  the  inferior  dental  foramen.  For 
disarticulation  of  the  jaw  the  foramen  ovale  should 
be    infiltrated. 


ANESTHESIA   OF   THE   HEAD   AND   NECK. 


105 


REGIONAL  ANESTHESIA  OF  THE  TONGUE,  FLOOR 
OF  THE  MOUTH,  TONSILS,  AND   PALATE. 

Nerve   Supply. 

The  lingual  nerve  supplies  two-thirds  of  the 
anterior  portion  of  the  tongue  and  the  floor  of 
the  mouth;  the  glosso-pharyngeal  nerve  supplies 
the  posterior  portion  of  the  tongue,   the  region  of 


Fig.  n. — Sensory  distributions  on  the  tongue.  {Tes- 
tut.)  (1)  Lingual.  (2)  Glossopharyngeal.  (3)  Superior 
laryngeal. 

the  tonsils,  and  the  pharynx;  the  superior  maxil- 
lary nerve  supplies  the  soft  palate  and  the  ante- 
rior pillars  of  the  fauces,  and  the  superior  laryn- 
geal  nerve   supplies   the   epiglottis. 

One  may  therefore  infiltrate  the  following 
trunks : 

(i)  The  lingual  nerve,  within  the  inferior  den- 
tal foramen,  desensitizing  two-thirds  of  the  ante- 
rior portion  of  the  tongue  and  the  floor  of  the 
mouth. 


106  REGIONAL   ANESTHESIA. 

(2)  The  superior  laryngeal  nerve,  in  the  thyro- 
hyoid space  (see  page  116). 

(3)  Infiltration  of  the  glosso-pharyngeal  and 
pneumogastric  nerves  should  be  avoided  because 
it  is  dangerous;  peripheral  infiltration  must  be 
substituted. 

Technique. 

Excision  of  a  Tumor  of  the  Margin  of  the 
Tongue. — A    triangle   enclosing    the    tumor    is    out- 


Fig.  78. — Anesthesia  of  the  tongue  and  the  buccal  floor. 
(Pauchet.)  With  a  finger  placed  over  the  base  of  the  tongue 
the  needle  is  introduced  above  the  hyoid  bone  until  its  point 
almost  touches  the  finger  on  the  tongue,  coming  to  rest  just 
beneath  the  mucous  membrane. 

lined  by  two  V-shaped  bands  of  infiltration.  The 
growth  can  then  be  excised  without  hemorrhage 
or   pain. 

Excision    of    an    Extensive    Cancer    or    Large 
Cyst   of  the   Floor   of   the  Month. — A   long  needle 


ANESTHESIA    OF    THE    HEAD    AXD    XECK. 


107 


is  introduced  under  the  chin,  above  the  hyoid  bone, 
and  pushed  in  vertically  toward  the  base  of  the 
tongue,  being  received  against  the  tip  of  the  left 
index  finger,  introduced  into  the  mouth  as  for  tra- 
cheotomy. This  vertical  route  is  first  infiltrated, 
then  through  the  same  wheal  one  injects  succes- 
sively from  top  to  bottom  and  further  and  fur- 
ther out,  as  many  layers  as  are  necessary  to  form 
a  fan  shaped  infiltrated  region,  the  sides  of  which 
extend    to    the    maxillary   bones,    thus    blocking   off 


Fig.  79. — Injection  for  transverse  incision  of  the  cheek  for 
cancer  of  the  pharynx  or  posterior  cancer  of  the  tongue. 
{Pauchet.) 


all  the  nerves  of  the  anterior  portion  of  the 
tongue. 

Restricted  Operations  on  the  Floor  of  the  Month. 
— Small  tumors  of  the  floor  of  the  mouth  may  be 
infiltrated  in  a  circle,  by  an  injection  made  from 
under  the  chin,  with  the  needle  alv/ays  guided  by 
the  finger   in   the  mouth. 

Removal  of  Extensive  Cancer  of  the  Tongue, 
Floor  of  the  Month,  and  Tonsils. —  (i)  The  two 
inferior   maxillary  nerves   are   infiltrated   at   the   in- 


108 


REGIONAL   ANESTHESIA. 


ferior  dental  foramen:  (2)  the  base  of  the  tongue 
is  infiltrated  by  a  subhyoid  injection;  (3)  peri- 
oheral    infiltration    of    the    operative    field    is    insti- 


Fig.  80. — Tonsillectomy  (Laboure.)  The  superior  pole  is 
infiltrated  by  an  injection  made  in  the  upper  part  of  the  an- 
terior pillar.  An  injection  at  the  base  of  this  pillar  infiltrates 
the  inferior  pole.     Quinine  is  employed. 


Fig.  81. — Tonsillectomy.  (Laboure.)  The  inferior  pillar 
is  completely  infiltrated.  Quinine  infiltration  of  the  tonsil  has 
been  instituted    (white  crescent) 

tuted;    (4)    in    some    cases    the    Gasserian    ganglion 
of  one   side   is   also   infiltrated. 

Operations  on  the  Palate. — Anesthesia  of  both 
the  soft  and  hard  palate  may  be  obtained  by  mak- 
ing  an    injection   under    the   mucous   membrane    in- 


ANESTHESIA    OF    THE    HEAD    AND    NECK.  109 

side  of  the  large  molars  and  behind  the  middle 
incisors.  For  resection  of  the  bony  hard  palate, 
the  two  superior  maxillary  nerves  should  be  in- 
filtrated. 

In  staphylorrhaphies  one  should  avoid  using  too 
much  adrenin  at  the  point  where  the  flaps  are  to 
be  made. 

Tonsillectomy  (Figs.  80  and  81). — Infiltrate 
the  two  nerve  pedicles  of  the  tonsil :  ( i )  At  the 
lower  portion  of  the  anterior  pillar;  (2)  at  the 
upper  part  of  the  vestibule,  at  the  junction  of  the 
posterior    and    anterior    pillars. 

REGIONAL  ANESTHESIA  IN  OPERATIONS 
ON  THE  NECK. 

Infiltration   of   the   Cervical   Roots. 

The  soft  tissues  of  the  anterior  portion  of  the 
neck  are  supplied  by  the  anterior  branches  of  the 
2d,  3d,  and  4th  cervical  nerves,  of  which  the  ter- 
minal branches — auricular^  mastoid,  transverse  cer- 
vical, and  supraclavicular, — emerge  at  the  posterior 
margin    of   the    sterno-mastoid   muscle    (Fig.    82). 

Infiltration  of  these  terminal  branches  at  the 
posterior  border  of  the  sterno-cleido-mastoid  de- 
sensitizes the  skin  alone  and  this  is  rarely  suffi- 
cient. In  order  to  obtain  a  deep  anesthesia,  the 
nerves  must  be  reached  at  their  emergence  from 
the  spinal  column,  on  a  level  with  the  transverse 
processes  of  the  3d,  4th,  and  5th  vertebrae  (Fig.  86). 

The  distribution  of  the  cervical  trunks  is  as  fol- 
lows  (see  Figs.  85   and  87) :     The  second  cervical 


110  REGIONAL   ANESTHESIA. 

supplies    the    nape    of    the    neck    and    the    occipital 
region.      The    third    cervical    supplies    the    antero- 


Fig.  82. — Superficial  branches  of  the  cervical  plexus 
(Hirschfeld.)  These  branches  should  be  desensitized  by  in- 
filtration of  the  soft  tissues  lying  between  the  mastoid  and 
the  upper  margin  of  the  cricoid  cartilage,  following  a  ver- 
tical line  and  injecting  through  3  wheals. 


lateral  portions  of  the  neck,  from  the  lower  jaw 
to  the  shoulders  and  the  upper  portions  of  the 
arms.     The  roots  of  the  second,  third,  and  fourth 


ANESTHESIA    OF   THE    HEAD   AND    NECK. 


Ill 


cervical  supply  the  cervical  plexus  (see  Figs.  83 
to  85).  It  is  these  roots,  therefore,  that  must  be 
reached   in  operating  on  the  neck. 

Technique. — The    line    of    skin    infiltration    for 
the    cervical    plexus    is    vertical,    i.e.,    parallel    with 


Ophthalmic 


Greater 
occipital 

Mastoid  branch 
of  great  auricular 


Occipital 
foramen 

Great  auricular 


Third  cervical 


Phrenic 


Supraclavicular 


Fig.  83. — Sensory  areas  of  the  superficial  branches  of 
the  cervical  plexus.     (Testut.) 


the  spinal  column,  and  is  determined  by  the  two 
following  points:  Above,  a  point  one  finger- 
breadth  below  the  tip  of  the  mastoid,  corre- 
sponding to  the  angle  of  the  jaw;  below,  a  point 
5  centimeters  lower  down  and  corresponding  to 
the  superior  border  of  the  thyroid  cartilage.  Using 
a  6-centimeter   needle,   the  bone   should  be  encoun- 


112  REGIONAL   ANESTHESIA. 

tered  at  a  depth  of  5  centimeters,  and  a  fan- 
shaped  injection  of  a  i  per  cent,  solution  of  pro- 
caine-adrenin  made  there.  About  25  mils  is  suffi- 
cient.     The    needle    should    be    introduced    through 


Fig.  84. — Anesthesia  of  the  cervical  plexus.  (Pauchet.) 
On  a  line  joining  the  mastoid  and  the  tubercle  of  the  6th  cer- 
vical transverse  process  (1  to  3)  a  layer  of  soft  tissues,  ex- 
tending from  the  skin  to  the  spinal  column  and  from  the 
lower  border  of  the  inferior  maxillary  (1)  to  a  point  situated 
on  a  level  with  the  cricoid  (2),  is  infiltrated. 


the  wheals  indicated  and  the  fluid  injected  as  it 
is  withdrawn.  There  is  thus  infiltrated  an  area 
about  5  centimeters  square,  outlined  on  the  skin 
by  the  preceding  line,  above  and  below  by  a  per- 
pendicular line  passing  from  these  points  to  the 
vertebral    column,    and    involving    the    tissues    bor- 


ANESTHESIA    OF   THE   HEAD    AND    NECK. 


113 


Fig  85.— Anesthesia  resulting  from  paravertebral  injec- 
tion of  the  cervical  plexus  (anterolateral  and  posterior  view). 
{Testut.) 


Fig,  36. — Paravertebral  anesthesia  of  the  neck.  {Danys.') 
Needle  (1)  is  aimed  directly  at  the  lateral  portion  of  the  ver- 
tebra, but  it  almost  touches  the  vertebral  artery.  Needle  (2) 
(Danys)  enters  2  centimeters  from  the  spinous  process,  comes 
in  contact  with  the  lateral  mass  of  the  vertebra,  and  reaches 
the  nerve  without  danger  to  the  vertebral  artery. 


114 


REGIONAL   ANESTHESIA. 


dering   the   column   between   the   two   perpendicular 
lines    (Fig.  84). 


K.  r 


o  cm 


r7«C>k 


'-•V'  aVj^       ^' 

;:;  c.r;'V  r 


-..^^-''t"^w-sl/--V-x:v.- 

::::^'-t:-''-":--'--..Dni.-:<"-:.::?----:::--;- 


x^^    U--^^,/ ::  \.^: J     /  / 

Fig.  87. — Paravertebral  anesthesia  of  the  neck.  (Pauchet.) 
A  B  extends  from  the  mastoid  to  the  6th  cervical  vertebra. 
The  white  and  black  dots  indicate  the  dermal  wheals.  Along 
this  line  the  needle  enters  transversely  to  infiltrate  the  nerve 
(direct  route).  The  figure  shows  the  needle  penetrating  ob- 
liquely {Danys)  2  centimeters  beyond  the  spinous  process  and 
following  the  lateral  masses  of  the  vertebrae.  As  soon  as  it 
has  passed  these  a  strong  solution  of  procaine-adrenin  is 
injected. 


Danys  advises  that  the  needle  be  introduced 
through  the  posterior  surface  of  the  neck,  2  centi- 
meters from  the  interspinous  line,  in  order  to  avoid 


ANESTHESIA    OF   THE   HEAD    AND   NECK. 


115 


a  possible  penetration  of  the  needle  into  the  inter- 
transverse space  and  a  consequent  wounding  of 
the  vertebral  artery.  We  prefer,  however,  the 
method  described  above,  care  being  taken  not  to 
penetrate  too  deeph^ 


Fig.  88. — Peripheral  infiltration  for  laryngectomy  or  laryn- 
gotomy,  circumscribing  the  larynx.  (Laboure.)  The  wheals 
here  shown  should  be  joined  by  subcutaneous  and  subfascial 
bands  of  infiltration.  The  wheal  corresponding  to  the  thyro- 
hyoid space  is  missing  from  the  polygon.  Infiltration  of  the 
two  superior  laryngeal  nerves  through  the  thyro-hyoid  mem- 
brane is  sufficient. 


Anesthesia   of   the   Laryngeal 
Nerve  Trunks. 

Two  nerves  supply  the  larynx, — the  superior 
laryngeal,  and  the  inferior  or  recurrent  laryngeal. 
The  latter  is  almost  exclusively  motor,  whereas 
the  first  is  entirely  sen.sory    (Fig.  88). 


116  REGIONAL   ANESTHESIA. 

Infiltration  of  the  Superior 
Laryngeal  Nerve. 

The  superior  laryngeal  arises  from  the  in- 
ferior pole  of  the  plexiform  ganglion.  It  is  held 
against  the  pharynx  by  the  internal  carotid,  then 
by  the  beginning  of  the  facial  and  lingual  arteries, 
Slightly  above  the  greater  cornu  of  the  hyoid  bone 
it   divides   into    its   two   terminal   branches: 

(i)  The  superior  branch  {external  laryngeal) 
follows  the  vertical  insertion  of  the  inferior  con- 
strictor over  the  thyroid  gland  to  the  crico-thyroid 
muscle,  which  it  supplies,  and  terminates  in  the 
subglottic  portion  of  the  mucous  membrane  of  the 
larynx. 

(2)  The  inferior  branch  (infernal  laryngeal) 
continues  in  the  direction  of  the  common  trunk, 
passes  between  the  thyroid  muscle  and  the  hyo- 
thyroid  membrane,  penetrating  through  the  middle 
of  this  membrane,  and  divides  into  superior  ter- 
minal filaments  for  the  epiglottis  and  base  of  the 
tongue,  inferior  filaments  for  the  mucous  membrane 
of  the  larynx  and  the  arytenoids,  and  an  anasto- 
motic termination  for  the  recurrent  nerve  (ansa 
Gallieni). 

Technique. — The  sensory  innervation  of  the 
larynx  is  constituted  almost  entirely, — above  the 
vocal  cords  at  any  rate, — by  the  superior  laryn- 
geal. As  already  stated,  this  nerve  penetrates  im- 
mediately behind  the  posterior  extremity  of  the 
greater  cornu  of  the  hyoid  bone,  under  the  in- 
ferior border  of  this  bone.  It  follows  closely  the 
thyro-hyoid  membrane,  courses  forward,  perforates 


ANESTHESIA    OF    THE    HEAD    AND    NECK.  117 

this  membrane,  and  supplies  the  laryngeal  mucous 
membrane  and  the  neighboring  portions  of  the 
pharynx.  A  needle  6  centimeters  long  is  intro- 
duced in  the  median  line  between  the  thyroid  car- 
tilage and  the  hyoid  bone,  into  the  thyroid  liga- 
ment. Once  it  is  in  this  ligament,  the  needle  is 
made  to  approach  the  greater  cornu  of  the  hyoid 
bone,  which  is  easily  felt  with  the  finger.  This 
ligament  is  now  infiltrated  on  both  sides,  to  the 
right  and  to  the  left,  with  5  to  lo  mils  of  a  i 
per   cent,   procaine-adrenin   solution. 

Infiltration  of  the  Recurrent  Laryngeal  Nerve. 
— Even  if  this  nerve  were  exclusively  motor,  its 
infiltration  would  be  justified  to  avoid  spasm  of 
the  larynx,  but  actually  it  is  a  mixed  nerve. 
Couzard  and  Chevrier  infiltrate  it  thus:  "Intro- 
duce a  straight  needle  into  the  angle  formed  in 
the  median  line  by  the  superior  border  of  the  thy- 
roid, injecting  obliquely  below,  behind,  and  out- 
side of  the  angle;  come  into  contact  with  the  in- 
ternal face  of  the  thyroid  cartilage;  guide  the 
needle  diagonally  toward  the  postero-inferior  angle 
of  this  cartilage,  and  inject  the  solution;  it  will 
distend  the  recess  and  bathe  the  terminal  branches 
of  the  recurrent  nerve."  One  to  2  mils  of  solu- 
tion  suffices. 

These  infiltrations  of  the  trunks  do  not  render 
local  anesthesia  unnecessary.  Spraying  with  a  20 
jjer  cent,  solution  of  cocaine,  tamponage  with  a  10 
per  cent,  solution,  and  submucous  injection  of  i 
per  cent,  procaine-adrenin,  are  all  advantageous 
adjuncts. 


118  REGIONAL   ANESTHESIA. 


Operations. 


( 1 )  Endolaryngeal  Intervention. — (a)  One  should 
first  anesthetize  by  spraying  and  tamponing  with 
a  lo  to  20  per  cent,  solution  of  cocaine  the  base 
of  the  tongue,  the  pillars  of  the  fauces  and  the 
larynx. 

(b)  Infiltration  of  the  two  superior  laryngeal 
nerves   should  be  carried   out. 

(2)  Tracheotomy,  Laryngo-Hssure,  and  Laryn- 
gostomy. — The  methods  of  anesthesia  described 
above  should  be  employed,  and  intradermal  and 
subcutaneous,  peripheral,  and  trunk  anesthesia 
added.  In  cases  of  laryngo-fissure  and  laryngos- 
tomy,  as  soon  as  the  larynx  is  open,  one  may 
apply  tampons  moistened  with  a  strong  solution  of 
cocaine  to  the  mucous  membrane. 

(3)  Laryngectomy  and  Goiter  Operations. — 
These  are  more  extensive  procedures,  for  the  per- 
formance of  which  it  is  necessary  to  infiltrate  the 
trunks  of  the  nerves  of  the  plexus  and  the  larynx, 
and  to  institute  a  subcutaneous  peripheral  infiltra- 
tion surrounding  the  larynx  or  the  tumor  at  a 
distance. 

The  harmful  actions  of  chloroform  or  ether 
upon  the  heart,  lungs,  and  liver  are  thus  avoided, 
to  the  great  benefit  of  patients  whose  respiration  is 
affected  by  disease  or  who  are  diabetic.  Again, 
regional  anesthesia  permits  the  patient  to  clear  his 
bronchi  during  the  course  of  the  operation,  thus 
avoiding  broncho-pneumonia.  Shock  is  also  con- 
siderably diminished. 


ANESTHESIA    OF    THE    HEAD    AND    NECK. 


119 


(4)  Ligation  of  the  External  Carotid  or  Thy- 
roid Arteries. — The  cervical  plexus  is  first  infil- 
trated, and  there  is  then  circumscribed  under  the 
skin  and  fascia  a  quadrilateral  area  extending 
beyond   the    limits    of   the   incision. 

(5)  Removal  of  Enlarged  Glands  and  Tumors 
of  the  Neck. — The  cervical  plexus  of  one  or  both 


pig_  89.— Infiltration  for  thyroidectomy.  (Panchet.)  The 
injection  to  the  right  infiltrates  the  branches  of  the  cervical 
plexus  along  the  transverse  processes  of  the  vertebree  (from  1 
to  2).  The  mass  is  surrounded  at  a  distance  with  a  sub- 
cutaneous and  subfascial  band  of  infiltration  (2,  3,  4,  5,  and  6). 
We  have  performed  about  250  strumectomies  by  Kocher's 
method  without  mortality. 


sides  is  infiltrated  and  the  tumor  or  lymphatic 
mass  circumscribed  by  peripheral  injection  of  a  ^ 
per  cent,  procaine-adrenin  solution.  If  the  mass 
of  the  tumor  or  lymphatics  extends  posteriorly  so 
as    to    interfere    with    the    passage    of    the    needle, 


120 


REGIONAL   ANESTHESIA. 


the  latter  may,  instead  of  being  introduced  trans- 
versely or  in  front,  be  passed  in  near  the  inter- 
spinous  line,  in  an  anterior  or  in  any  intermediate 
oblique    direction. 

(6)   Infrahyoid  and  Suprahyoid  Pharyngotomy. 
— The  thyroid  membrane  is  infiltrated  and  a  peri- 


Fig.  90. — Removal  of  carcinoma  of  the  larynx  under 
regional  anesthesia.  (Pauchet.)  The  organ  has  been  opened 
up  posteriorly;  the  tumor  is  to  be  seen  on  the  right  vocal  cords. 


pheral  lozenge-shaped  area  of  infiltration  made 
over  the  inferior  maxillary  and  the  thyroid  car- 
tilage. During  the  course  of  the  operation  it  is 
sometimes  necessary  to  infiltrate  the  tumor  over 
its  entire  external  surface. 


ANESTHESIA    OF   THE   HEAD   AND   NECK.  121 

(7)  Thyroidectomy. — Six  dermal  wheals  are 
made  (Figs.  89  and  90).  Points  i  and  2  cor- 
respond to  the  line  of  the  transverse  processes 
and  serve  as  landmarks  in  instituting  paraverte- 
bral anesthesia  of  the  neck.  All  the  tissues,  epi- 
dermis, muscles,  and  nerves  are  thus  infiltrated 
until  the  cervical  plexus   is  reached. 


Fig.  91. — Paravertebral  anesthesia  of  the  neck.  {Danys.) 
This  figure  shows  the  two  methods  of  reaching  the  nerve  as 
it  emerges  from  the  spinal  canal.  Needle  1  aims  transversely 
for  the  nerve,  but  it  runs  a  risk  of  injuring  the  artery.  Needle 
2  enters  2  centimeters  from  the  median  line,  follows  the  line 
of  the  vertebrae,  comes  in  contact  with  the  transverse  process, 
and  finally  reaches  the  nerve,  while  avoiding  the  vertebral 
artery. 


With  a  needle  9  centimeters  long,  a  subcuta- 
neous and  subfascial  band  is  infiltrated  through 
the  dermal  wheals  (Figs.  89  and  90).  One 
hundred  grams  of  a  ^  per  cent,  solution  of  pro- 
caine-adrenin  are  required.  This  procedure  may 
also  be  employed  in  the  removal  of  malignant 
tumors. 


122 


REGIONAL   ANESTHESIA. 


(8)  Total  Laryngectomy. — A  subcutaneous  hexa- 
gon is  made,  extending  from  a  point  slightly 
above    the    hyoid   bone   to    the  angle  of    Louis.      A 


Fig.  92. — Infiltration  of  the  anterior  aspect  of  the  neck. 
{Labonre.)  This  is  intended  for  major  operations  in  this 
region,  e.g.,  for  cancer  of  the  larynx,  goiter,  extirpation  of 
lymphatics  of  the  neck  for  cancer  of  the  tongue,  etc.  A,  B,  C, 
and  D  indicate  the  method  of  paravertebral  injection  of  the 
cervical  nerves.  Dermal  wheals  are  made  above  and  below 
to  circumscribe  the  operative  field. 


paravertebral  infiltration  is  then  conducted  through 
two  dermal  wheals,  as  in  goiter,  for  the  purpose 
of    anesthetizins:    the    transverse    cervical    branch. 


ANESTHESIA    OF   THE   HEAD   AND    NECK.         123 


Fig.  93. — Large  adamantoma  of  the  lower  maxillary.  (Pauchet.) 
On  the  lower  part  of  the  tumor  is  seen  a  white,  cross-shaped  scar, — ■ 
evidence  of  an  operation  carried  out  a  few  years  before.  This  case 
had  been  recently  diagnosed  "inoperable  sarcoma."  The  tumor  com- 
municated with  the  mouth  and  secreted  pus  abundantly.  _  Insomnia. 
Liquid  diet.  Anesthesia  was  commenced  by  paravertebral  injection  of 
the  cervical  plexus,  injection  of  the  superior  maxillary  nerve  by  the 
orbital  route,  and  simple  infiltration  of  the  chin  and  lower  lip  in  the 
median  line.  These  three  anesthetizing  injections  enabled  the  operator 
to  ligate  the  external  carotid  and  perform  a  section  from  the  middle  of 
the  neck  to  a  point  beyond  the  eyelid,  extending  through  the  chin  and 
cheek  (see  the  succeeding  figures). 


124 


REGIONAL   ANESTHESIA. 


Finally,    the    superior    laryngeal    nerve    is    anesthe- 
tized.    One  must  not  forget  to  spray  the  pharynx 


Fig.  94. — Second  stage  of  the  operation:  Ligation  of  the 
external  carotid  has  been  effected.  The  scalpel  has  just 
divided  the  skin  in  front  of  the  tumor. 


with  cocaine,  in  order  to  suppress  the  reflexes  of 
deglutition  and  prevent  coughing.  Two  hundred 
to  250  grams  of  a  ^  per  cent,  solution  of  pro- 
caine-adrenin  are   required   for   this   operation. 

It  is  in  cases  such  as  these  that  regional  anes- 
thesia  exhibits   its   superior   degree  of  utility. 


ANESTHESIA   OF   THE   HEAD   AND   NECK. 


125 


Fig.  95.— Third  stage:  Resection  of  the  jaw  has  been  completed. 
To  the  left  is  still  seen  the  needle  which  has  served  to  infiltrate  the 
foramen  ovale  (inferior  maxillary).  The  external  carotid  having  been 
previously  ligated,  there  is  not  much  hemorrhage. 


126 


REGIONAL   ANESTHESIA. 


Fig.  96. — Anesthesia  by  infiltration  of  the  cervical  plexus  and 
superior  and  inferior  maxillary  nerves.  (Pauchet.)  An  esophageal 
tube  has  been  introduced  in  the  nose.  The  patient  is  to  be  fed 
through  it. 


ANESTHESIA    OF   THE    HEAD   AND    NECK.  127 


Fig.  97. — Anesthesia  of  the  cervical  plexus  and  inferior  maxillary 
nerve  for  amputation  of  the  tongue  by  the  subhyoid  route.  (Pauchet.) 
The  infrahyoid  floor  has  been  incised,  and  the  tongue  drawn  out.  ■ 


CHAPTER   V. 

ANESTHESIA  OF  THE  THORAX  AND  ABDOMEN. 

Operations  upon  the  trunk  may  be  performed 
under  spinal  anesthesia  by  means  of  cocaine  (Le 
Filhatre)  or  other  drugs  introduced  more  or  less 
high  up  (Jonnesco)  after  a  series  of  paraverte- 
bral injections,  which  constitutes  the  ideal  regional 
anesthesia  for  the  upper  portions  of  the  trunk,  or 
by  lumbosacral  injections  (Le  Filliatre).  For  in- 
tra-abdominal operations  and  operations  in  the  pel- 
vis and  on  the  lower  extremities,  injection  of  procaine- 
adrenin  directly  into  the  lumbar  canal  offers  the 
simplest  and  most  complete  form  of  anesthesia. 

Intraspinal  Anesthesia. 

Personally  we  prefer  regional  anesthesia  for  all 
operations  upon  the  head,  face,  neck  and  thorax, 
as  well  as  all  other  operations  of  a  local  charac- 
ter. But  for  amputation,  resection  or  other  ex- 
tensive procedures  on  the  lower  extremities,  as 
well  as  for  major  intra-abdominal  operations  on 
the  liver,  stomach,  intestines,  and  pelvic  organs, 
intraspinal  anesthesia  possesses  certain  pronounced 
advantages.  It  is  particularly  valuable  in  opera- 
tions for  intestinal  occlusion,  as  it  paralyzes  and 
softens  the  abdominal  wall  and  contracts  the  in- 
testine, practically  eliminating  the  risk  of  fecal 
(128) 


THORAX    AND    ABDOMEN.  129 

vomiting  and  thereby  aiding  toward  a  favorable 
prognosis. 

We  do  not  advocate  intraspinal  anesthesia  for 
any  operation  in  which  regional  anesthesia  is  in- 
dicated, e.g.,  in  hemorrhoids,  varicocele,  perineor- 
rhaphy, prostatectomy,  amputation  of  the  foot,  suture 
of  the  patella,  nephrectomy,  cholecystotomy,  and 
all   operations   on   the   head,   neck   and   thorax. 

The  spinal  cord  proper  terminates  at  about  the 
level  of  the  junction  of  the  second  and  third  lum- 
bar vertebrae,  where  it  becomes  filiform.  It  is 
entirely  safe  to  inject  directly  into  the  spinal  canal 
at  the  space  between  the  third  and  fourth  (Tuf- 
fier),  fourth  and  fifth  (Chaput),  and  fifth  lumbar 
vertebra  and  sacrum  (Le  Filliatre),  and,  with  a 
little  care  not  to  enter  the  cord,  between  the  first 
and   second   lumbar   vertebrae. 

Injection  into  any  one  of  the  inter-vertebral 
spaces  of  the  lumbar  region  produces  insensibility 
of  the  lower  part  of  the  abdomen  and  the  lower 
extremities. 

Under  this  form  of  anesthesia  we  have  per- 
formed, at  the  Molitor  Hospital,  operations  upon 
every   portion   of   the   leg  and   thigh. 

Some  little  familiarity  and  practice  is  required 
for  the  successful  injection  of  the  spinal  region. 
It  is  easiest  to  find  entrance  to  the  canal  between 
the  last  lumbar  vertebra  and  sacrum,  because  here 
the  space  is  wide,  but  as  a  matter  of  fact,  it  is 
not  dif^cult  to  efTect  an  entrance  at  any  one  of 
the  interspaces  mentioned. 


130  REGIONAL   ANESTHESIA. 

Injections  into  the  spinal  canal  are  greatly- 
facilitated  by  placing  the  patient  in  a  sitting  posi- 
tion with  head  bent  over  on  the  arms — the  latter 
folded  upon  the  knees, — and  the  back  made  to 
*'bow"  as  much  as  possible  in  order  to  throw  the 
spinous  processes  into  the  greatest  possible  promi- 
nence. 

The  same  degree  of  aseptic  precaution  should 
be  taken  for  injecting  the  spinal  canal  as  for  a 
laparotomy,  both  as  regards  the  surgeon  and  the 
patient. 

A  strong  needle  of  rather  large  caliber,  8 
centimeters  long,  should  be  selected.  With  the 
index  finger  of  the  left  hand  the  space  to  be  injected 
is  found,  ^  centimeter  from  the  median  line  of 
the  spine,  midway  between  two  adjacent  spinous 
processes.  In  the  center  of  this  space  the  needle 
is  introduced  in  a  straight  line,  pointing  slightly 
inward  toward  the  median  line  (Fig.  98).  At  a 
certain  depth,  which  varies  according  to  the  con- 
formation of  the  patient,  the  operator  senses  con- 
tact with  the  ligamenta  subfliava  and  the  inter- 
laminar  ligament,  some  force  being  required  to 
penetrate  and  the  operator  experiencing  somewhat 
the  sensation  of  piercing  a  tense  drum  head.  As 
the  needle  is  pushed  through,  the  silver  wire  is 
removed  from  its  lumen  from  time  to  time  to  see 
if  a  drop  of  cerebrospinal  fluid  will  appear.  When 
the  fluid  drops  more  or  less  rapidly,  according  to 
the  intraspinal  tension,  the  syringe,  containing  2 
mils  of  a  4  per  cent,  solution,  is  adjusted,  the 
spinal    fluid    slowly   drawn    out   to    complete    exten- 


THORAX    AND    ABDOMEN. 


131 


sion  of  the  syringe,  the  fluid  then  slowly  injected 
in  part,  and  the  piston  redrawn  and  reinserted 
several  times  to  mix  the  solution  with  the  spinal 
fluid   and   cause    it   to    be   more    generally    diffused 


i— J. 


Fig.  98. — Showing  point  of  entrance  into  the  spinal 
canal.     (Pauchet.) 


in  the  spinal  canal.  When  the  syringe  has  been 
finally  emptied  into  the  canal,  the  needle  is  with- 
drawn by  a  quick  movement,  slipping  the  index 
finger  of  the  left  hand  over  the  puncture  for  a 
moment,  then  touching  it  with  a  drop  of  iodine 
tincture.      In    from   five   to   fifteen   minutes   the  pa- 


132  REGIONAL   ANESTHESIA. 

tient  will  experience  complete  insensibility  of  the 
parts    supplied   by   the   nerves   involved. 

If  the  injection  be  made  between  the  12th  dor- 
sal and  1st  lumbar  vertebrae,  it  will  produce  a 
complete  anesthesia  of  the  abdominal  contents — 
stomach,  liver,  intestines,  abdominal  walls — as  well 
as  the  lower  extremities.  If  it  be  made  between  the 
fifth  lumbar  and  sacrum  it  will  anesthetize  the 
perineum,  anus  and  lower  extremities.  Both  to- 
gether are  recommended  for  abdomino-pelvic  oper- 
ations such  as  hysterectomy  or  extensive  extirpa- 
tion of  the  rectum    (Jonnesco). 

For  feeble,  old  individuals,  and  the  cancerous, 
cachectic,  and  tuberculous,  it  is  not  necessary  to 
employ  the  full  strength  of  dose,  as  for  the  vigor- 
ous patient.  The  anesthesia  is  more  readily  in- 
duced  in  the   feeble. 

As  a  precautionary  measure  it  is  well  to  in- 
ject, one  hour  before  the  operation,  an  ampoule 
of  scopolamine-morphine  and  one  of  strychnine  or 
sparteine. 

Equalization  of  the  efifect  of  the  anesthetic  is 
greatly  facilitated  by  the  repeated  filling  and  par- 
tial reinjection  of  the  contents  of  the  syringe  into 
the  spinal  canal.  If  this  movement  is  not  readily 
performed  and  something  seems  to  prevent  an 
easy  flow  to  and  from  the  syringe,  the  action  of 
the  anesthetic  is  likely  to  be  imperfect. 

Immediately  after  the  injection  is  made  the  pa- 
tient should  be  placed  recumbent  upon  the  opera- 
ting table  and  covered  warmly.  For  him  to  re- 
main sitting  up  involves  risk  of  an  attack  of  syn- 


THORAX    AND    ABDOMEN.  133 

cope.  The  ears  should  be  stopped  with  cotton, 
the  eyes  bandaged,  if  necessary,  and  complete 
silence  ordered.  The  anesthesia  continues  for  an 
hour   or  more. 

Complications. — {a)  If  cerebrospinal  fluid  fails 
to  flow  from  the  needle,  either  the  direction  of 
the  needle  is  bad  and  the  point  has  not  penetrated 
the  spinal  canal,  or  the  needle  is  plugged.  Only 
two  or  three  attempts  are  required  for  the  oper- 
ator to  feel  confident  when  he  is  traversing  the 
inter-laminar  ligaments  separating  the  vertebrae. 
If  he  be  satisfied  that  the  direction  of  the  needle 
is  not  at  fault,  the  needle  should  be  withdrawn, 
aspirated  with  the  aid  of  a  syringe,  and  reintro- 
duced. 

{h)  If  pure  blood  appears,  the  needle  has  pene- 
trated a  vein  and  must  be  withdrawn  and  rein- 
troduced. If  the  liquid  is  mixed  with  blood,  one 
should  wait  a  moment  for  the  fluid  to  become 
clear.  To  inject  with  bloody  fluid  destroys  the 
effect   of   the   anesthetic. 

(c)  If  the  liquid  appears  only  in  slow  drops 
and  will  not  fill  the  syringe  when  aspiration  is 
made,  it  is  useless  to  push  the  attempt  farther. 
The  needle  must  be  withdrawn,  its  lumen  cleared 
with  the  aid  of  a  syringe,  and  the  needle  then  re- 
introduced. 

id)  Incomplete  anesthesia  or  absence  of  anes- 
thesia is  due  to  one  of  the  preceding  errors.  It 
does  not  occur  in  the  hands  of  an  experienced 
operator. 

Untoward    Sequckc. —  {a)     Retention     of     urine 


134  REGIONAL   ANESTHESIA. 

may  be  present  for  several  days.  The  patient  oc- 
casionally requires  daily  catheterization  for  a  week 
or   more. 

(b)  Vomiting  after  the  operation  is  very  un- 
common. 

(c)  Sciatic  neuralgia  occurs  when  the  operator 
introduces  the  needle  to  the  outer  side  of  the 
vertebra  and  pierces  a  nerve. 

(d)  Headache  often  follows  the  injection  and 
lasts  a  week.  If  it  is  violent,  lumbar  puncture  is 
necessary. 

(e)  Fecal  incontinence  during  the  operation. 
In  the  case  of  a  total  hysterectomy,  this  is  danger- 
ous as  the  fecal  matter  may  penetrate  the  vagina 
and  enter  the  abdominal  cavity.  It  is  wise  to 
tampon  the  vagina  to  safeguard  against  this 
difficulty. 

(/)  Fever.  The  temperature  may  rise  and  fall 
on  the  first  or  second  day;  this  is  devoid  of  sig- 
nificance. 

(g)  Labored  respiration  and  asphyxia  have 
appeared  where  the  injections  have  been  made 
high  up  and  the  anesthetic  has  affected  the  center 
of  respiration.  If  the  mind  is  clear,  the  patient 
should  be  made  to  talk  incessantly  and  draw  in 
and  blow  out  the  air.  If  necessary,  artificial  res- 
piration should  be  resorted  to.  As  soon  as  the 
effect  of  the  anesthetic  on  the  medulla  has  passed 
off,   natural    respiration   will   be   re-established. 

(h)  Death.  Among  2000  cases  Pauchet  has 
met  with  2   deaths.     In   5000  cases,  Jonnesco  had 


THORAX    AND,   ABDOMEN.  135 

no  death.  Le  Filliatre  has  had  no  deaths,  either. 
Leyden  has  had  2  deaths.  I  consider  spinal  anal- 
gesia as  involving  the  same  degree  of  immediate 
danger  as  does  chloroform. 

(i)  Nervous  Manifestations.  Among  5000 
cases  Jonnesco  observed  but  one  case  of  nervous 
disturbance.  Pauchet  met  with  one  case  of  blad- 
der retention  which  continued  for  three  months. 
Organic  affections  not  discovered  by  previous  ex- 
amination may,  of  course,  exist,  and  it  is  cer- 
tainly unjustifiable  to  attribute  accidents  appearing 
a  year  or  more  after  the  operation  to  the  effects 
of  the  anesthetic. 

Regions  Influenced. — Jonnesco  has  boldly  prac- 
tised injection  into  the  spinal  canal  along  its 
whole  length  and  specifies  the  effects  of  the  anes- 
thetic in  the  various  regions  as   follows : — 

(i)  Injection  between  the  3d  and  4th  cervical 
vertebrae:      Anesthesia   of   the  head   and   neck. 

(2)  Cervico-dorsal  injection,  immediately  below 
the  vertebra  prominens:  Thorax  and  upper  ex- 
tremities. 

(3)  Between  the  last  dorsal  and  first  lumbar: 
The  entire  abdomen,  testicles,  and  lower  ex- 
tremities. 

(4)  Between  the  last  lumbar  and  the  sacrum: 
The   pelvis,   perineum,   and   anus. 

Injection  at  two  points  has  been  recommended 
for  certain  operations,  viz.,  in  operations  upon  the 
thorax,  one  may  inject  *  at  the  cervico-dorsal  and 
dorso-lumbar    levels.      For    abdomino-pelvic    opera- 


136  REGIONAL   ANESTHESIA. 

tions,  one  should  inject  at  the  dorso-lumbar  and 
lumbo-sacral  levels.  For  other  operations,  one 
injection  suffices. 

Pauchet  says:  "I  do  not  practice  injection  of 
the  spinal  canal  at  a  point  above  the  intersection 
of  the  1 2th  dorsal  and  ist  lumbar,  which  insen- 
sibilizes  the  whole  abdomen  and  its  wall,  prefer- 
ring regional  and  local  anesthesia  for  all  opera- 
tions  above   this   level." 

As  in  the  administration  of  chloroform,  a  cer- 
tain degree  of  danger  attends  the  practice  of  spinal 
anesthesia,  but  the  procedure  is  free  of  the  post- 
operative dangers  incident  to  general  narcosis.  It 
does  not  affect  the  viscera  (lungs,  liver,  kidneys, 
or  suprarenal  capsules)  and  permits  of  highly 
traumatic  operations  (resection  of  the  femur,  dis- 
articulation of  the  hip)  with  very  minor  evidences 
of  shock.  It  renders  the  major  abdominal  opera- 
tions more  benign  because  it  makes  them  easier, 
serving  to  contract  the  intestine,  reducing  com- 
pletely the  rigidity  of  the  abdominal  wall,  and  pro- 
ducing  complete   "abdominal   silence." 

There  is  no  comparison  between  an  operation 
for  uterine  cancer,  for  cancer  of  the  rectum,  and 
notably  for  acute  occlusion  of  the  intestine,  under 
spinal   anesthesia   and   under   general   narcosis. 

Nerve-trunk   Anesthesia. 

The  thoracic  nerves  emerge  from  the  interver- 
tebral foramina  of  the  thoracic  portion  of  -'the 
spine  (Fig.    loi).      Immediately   after   their   emerg- 


-THORAX    AND.    ABDOMEN.  137 

ence  they  give  an  anastomotic  branch  to  the  sym- 
pathetic, and  afterward  divide  into  two  branches: 
an  anterior  and  a  posterior.  The  posterior  branch 
supphes  the  muscles  of  the  back  and  skin  in  the 
vicinity  of  the  midHne.  The  anterior  branches  or 
intercostal  nerves  are  situated  in  the  intercostal 
spaces  near  the  inferior  borders  of  the  ribs.     They 


Fig.  99. — Intercostal  nerves  and  their  distribution.  (Hirsch- 
feld.)  These  nerves  can  be  blocked  by  paravertebral  injection 
or  by  simple  intercostal  injection. 

are  at  first  in  contact  with  the  pleura,  near  the 
costal  angle;  afterward  they  pass  between  the  two 
intercostal   muscles    (Figs.   99   and    100). 

The  upper  dorsal  nerves  (Fig.  103,  D.  i,  2, 
and  3)  supply  the  internal  surfaces  of  the  arm 
and  of  the  forearm,  and  the  axillary  and  mam- 
mary regions  are  supplied  likewise  by  the  succeed- 
ing nerves,  down  to  the  seventh  dorsal  (D.  7), 
inclusive.  The  intercostal  nerves  from  the  8th  to 
the    1 2th    supply   the   thorax,    and   likewise   the   ab- 


138 


REGIONAL   ANESTHESIA. 


Fig.  100. — Intercostal  and  lumbar  nerves  and  their  distribu- 
tion. (Hirschfeld.)  The  figure  shows  the  anastomosis  of 
these  nerves  with  the  sympathetic.  The  needle  is  introduced 
close  enough  to  the  vertebral  column  to  infiltrate  the  com- 
municating ramus,  the  viscera  being  thus   anesthetized. 


THORAX    AND    ABDOMEN. 


139 


Fig.  101. — The  dorsal  nerves  at  their  points  of  emergence. 
(Testut.)  The  figure  shows  their  bifurcation  into  an  anterior 
branch  (intercostal)  and  a  posterior  branch  which  divides  into 
two  rami. 

ABC 


0 


'^i 


Fig.  102. — The  intercostal  space.  (SouHgoux.)  (A)  Pos- 
teriorly at  the  point  of  origin.  (B)  At  the  posterior  third. 
(C)  Middle  portion.  The  internal  intercostal  divides  to  sur- 
round the  blood-vessels  and  nerves. 


140 


REGIONAL   ANESTHESIA. 


Fig.  103.— Dorsal  paravertebral  anesthesia  for  the  viscera. 
(Pauchet.)  The  operator  is  shown  the  dorsal  points  which  shouldbe 
infiltrated  in  order  to  anesthetize  corresponding  viscera.  In  practice, 
one  should  inject  both  higher  and  lower  because  of  the  anastomoses. 
The  lung,  kidney,  biliary  passages,  and  spleen  are  anesthetized  by  an 
injection  made  upon  one  side  only.  For  other  organs  both  sides 
should  be  injected. 


THORAX  AND.  ABDOMEN. 


141 


domen.  Through  their  anastomoses  with  the  sym- 
pathetic, they  supply  with  sensation  the  following 
viscera:     Heart   (Fig.    103,  D.    i,  2,  and  3);  lungs 


Fig.  104. — The  lumbar  nerves  at  their  points  of  emergence. 
(Pauchet.)  These  nerves  are  accessible  between  the  trans- 
verse processes  of  the  lumbar  vertebrae,  as  are  the  intercostals 
below  the  ribs. 


(D.  I,  2,  3,  and  4);  stomach  (D.  6,  7,  8,  and  9); 
liver  and  hile  ducts  (D.  7,  8,  9,  and  10) ;  intes- 
tines (D.  9,  10,  II,  and  12);  kidneys  and  ureters 
CD.    10,   II,  and   12);  testicles,  ovaries,  and  uterus 


142 


REGIONAL   ANESTHESIA. 


(D.  10,  II,  and  12).  To  desensitize  the  viscera 
it  is  necessary  to  reach  the  anastomoses  with  the 
sympathetic    (Danys). 

The  lumbar  nerves  are  situated  between  the 
transverse  processes  of  the  lumbar  vertebrae  in 
front  of  the  intertransverse  muscles,  and  are  sur- 
rounded by  the  attachments  of  the  psoas  muscle 
(Figs.    100,    104,    105). 


Fig.  105. — The  lumbar  nerves  at  their  points  of 
emergence.     (Hirschfeld.) 


The  ilio-liypo gastric,  ilio-inguinal,  and  genito- 
crural  nerves,  supplying  the  anterior  abdominal  wall, 
follow,  as  the  12th  intercostal  nerves,  the  anterior 
surface  of  the  quadratus  lumborum,  i.e.,  course 
between  this  and  the  perirenal  adipose  tissue. 
After  the  2d  lumbar,  the  nerve  trunks  are  so 
closely  applied  against  the  vertebrae  that  they  can 
only  be  reached  by  injections  made  almost  in  con- 
tact with  the  vertebral  column  at  a  distance  of  3 
centimeters   from  the  median  line. 

The  intercostals  and  the  ist  lumbar  nerve  sup- 
ply not  only  the  thoracic  and  abdominal  wall,   but 


THORAX    AND    ABDOMEN.  143 

also  the  serous  membranes,  the  pleurse,  and  the 
parietal  peritoneum.  The  intermediate  intercostal 
nerves  do  not  anastomose  at  their  points  of  origin, 
but  from  the  12th  there  is  given  off  a  branch  to 
the  1st  lumbar  nerve.  At  the  level  of  the  skin  the 
regions  supplied  by  the  respective  intercostals  so  en- 
croach one  upon  the  other  that  the  blocking  of  a 
single  nerve  does  not  abolish  cutaneous  sensation; 
several  must  be  infiltrated  at  the  upper  part  of  the 
thorax  to  obtain  complete  anesthesia  of  a  given 
region.  The  skin  of  the  thorax  also  receives 
branches  from   the   cervical   and   brachial   plexuses. 

The  anesthesia  required  for  operations  upon 
the  spine,  thorax,  and  abdomen  may  be  obtained 
by  one  of   two   methods. 

In  the  case  of  a  circumscribed  operation,  such 
as  resection  of  one  or  two  ribs,  curettage  of  the 
sternum,  operation  for  appendicitis,  for  simple  her- 
nia, etc.,  injections  made  along  the  course  of  the 
nerves  supplying  the  field  of  operation,  as  des- 
cribed further  on,  will  yield  a  complete  anesthesia 
limited  to  the  parietes.  Such  injections  are  made 
around,  and  at  some  distance  from,  the  field  of 
operation.  The  procedure  varies  for  each  opera- 
tion in  accordance  with  the  nerve  supply.  This 
method  has  enabled  us  to  dispense  with  general 
and  spinal  anesthesia  for  a  number  of  operations, 
e.g.,  in  the  radical  cure  of  most  voluminous  her- 
nias. It  appears  to  us  the  ideal  procedure  for 
thoracotomy,  and  is  sufficient  for  appendectomy 
when  the  acute  attack  has  subsided  and  provided  the 
a])]jendix  and  cecum  are  free  from  adhesions.     It  en- 


144  REGIONAL   ANESTHESIA. 

ables  us  to  do  pylorectomy  for  cancer  and  very  consid- 
erable resections  of  the  intestines,  provided  the 
mesentery  is  injected  in  addition  with  a  i  per 
cent,  solution  of  quinine  and  urea  hydrochloride. 
When  the  operation  concerns  unilateral  viscera 
— kidneys,  liver,  spleen,  bile  ducts, — or  any  larger 
portion  of  the  trunk  or  abdomen,  it  is  preferable 
to  employ  the  following  method,  which  is  more 
precise  in  technique  and  permits  of  covering  a 
larger  field,   viz. : — 

Paravertebral   Anesthesia. 

Definition. — Paravertebral  anesthesia  consists  in 
bathing  the  thoracic  and  lumbar  nerves  at  their 
points  of  emergence  from  the  intervertebral  fora- 
mina of  the  dorsal  and  lumbar  spine  with  a  solu- 
tion of  procaine-adrenin.  The  injection  anesthe- 
tizes the  thoracico-abdominal  wall  and  even  the 
viscera  through  the  anastomoses  with  the  sympa- 
thetic. By  injecting  a  i  per  cent,  solution  of 
procaine-adrenin  3  to  4  centimeters  from  the 
median  line  in  the  intervertebral  spaces  the  sur- 
geon is  enabled  to  produce  complete  anesthesia  of 
the  thoracico-abdominal  wall  as  well  as  of  the 
unilateral  viscera  situated  on  the  same  side  and 
receiving  filaments  of  the  sympathetic  (liver,  bile 
passages,   spleen,   kidneys,   ureters). 

If  the  operator  desires  to  anesthetize  the  entire 
abdominal  contents  (intestines),  two  series  of  in- 
jections will  have  to  be  made,  one  to  the  right 
and   the    other    to    the    left    of    the    spinal    column; 


THORAX    AND    ABDOMEN. 


145 


but    such    an    event    is    exceptional.      Paravertebral 
anesthesia  is  useful  for  operations  upon  the  thorax, 


Line  of  skin 
infiltration 


Fig.  106. — Dorsal  paravertebral  anesthesia.  (Pauchet.) 
The  skin  is  inliltrated  with  a  band  1  centimeter  wide  at  a  dis- 
tance of  35  millimeters  from  the  median  line.  The  operator 
introduces  the  needle  through  this  band  and  feels  his  way. 
The  black  dots  show  where  the  needle  should  enter  to  reach 
the  rib,  somewhat  laterally  to  the  costo-vertebral  articulation. 
When  the  needle  has  come  in  contact  with  the  rib,  it  turns 
about  its  inferior  border  and  proceeds  toward  a  point  ^  centi- 
meter further  forward  and  inward  to  reach  the  sympathetic 
anastomosis.  It  should  be  noted  that  the  lower  angle  oi  the 
scapula  corresponds  to  the  spinous  process  of  the  seventh  dor- 
sal and  the  spine  of  the  scapula  to  the  third  dorsal. 


neck  and  abdomen,  the  breasts,  pleurae,  lungs,  and 
for  lateral  viscera,  including  the  kidneys,  liver, 
biliary  passages,   pylorus,   cecum,   etc. 

10 


146  REGIONAL   ANESTHESIA. 

Technique. — The  operator  should  remember  that 
the  thoracic  nerves  at  their  origin  are  located  at 
equal  distances  from  the  transverse  processes  and 
at  a  distance  of  2  centimeters  in  front  of  the 
intertransverse  space. 

The  spinous  processes  from  the  first  to  the 
sixth  are  situated  at  the  level  of  the  intertrans- 
verse spaces,  bounded  by  the  two  succeeding  ver- 
tebrae, and  at  the  level  of  the  nerve  immediately 
following.  Thus,  the  processes  D.  i  to  D.  6  (Fig. 
106)  correspond  to  pairs  D.  2  to  D.  7.  The 
processes  D.  7  to  D.  12  are  situated  opposite  the 
lower  portion  of  the  corresponding  intertransverse 
space   (Fig.    no). 

The  lumbar  nerves,  at  their  emergence  from 
the  conjugate  vertebral  foramina,  are  situated  at 
the  level  of  the  corresponding  spinous  process  and 
slightly  above  the  transverse  process  of  the  ver- 
tebra immediately  following  (Fig.  104).  They  are 
therefore  accessible  through  the  intertransverse 
spaces  at  a  distance  of  about  3  centimeters  out- 
side the  median  line,  and  are  situated  i  centimeter 
in  front  of  the  transverse  processes  (Fig.  106 
and   107). 

For  the  Dorsal  Nerves. — A  needle  6  to  9  centi- 
meters long  is  introduced  at  a  point  3^  centi- 
meters from  the  median  line.  At  a  depth  of  4  to 
5  centimeters,  when  the  needle  touches  the  rib, 
transverse  process  or  costo-vertebral  articulation, 
its  point  is  inclined  to  reach  the  lower  border  of 
the  bone.  Then,  at  an  angle  of  25°,  it  is  aimed 
at    the    middle    line,    and    its    progress    terminated 


THORAX    AND    ABDOMEN. 


147 


Yi  a  centimeter  beyond.  Next,  5  mils  of  the  1.5 
per  cent,  solution  is  injected,  or  7  to  8  mils  of 
the    I    per    cent,    solution.      It    is    well   to  move   the 


Fig.  107. — Intercostal  or  paravertebral  dorsal  anesthesia. 
(Pauchci.)  The  first  needle  is  directly  in  the  intercostal  space 
and  in  the  vicinity  of  the  nerve.  The  second  (dotted  line) 
has  at  first  come  in  contact  with  the  rib,  but  has  then  been 
given  an  oblique  direction  downward  and  has  reached  the 
vicinity  of  the  nerve. 


point  of  the  needle  to  and  fro  in  order  to  be  sure 
that  the  nerve  is  well  bathed  and  to  include  the 
anastomosis    of    the    sympathetic    and   the    posterior 


148 


REGIONAL   ANESTHESIA. 


as   well   as   the   anterior  branch   of   the   spinal   root 
(Fig.    io8). 

Two  difficulties  may  arise: 


Fig.  108. — Paravertebral  dorsal  anesthesia.  (Pauchet  and 
Sourdat.)  The  needle  enters  at  a  point  35  millimeters  from 
the  median  line,  close  to  the  inferior  border  of  the  rib;  then, 
at  a  point  1  centimeter  anterior  and  internal,  it  reaches  the 
nerve  root  and  impregnates  the  anastomosis  with  the  sym- 
pathetic. 


{a)  If  blood  comes  from  the  needle,  a  vein 
has  been  wounded.  The  position  of  the  needle 
must  be  changed,  otherwise  the  injection  will  pass 
into  the  vein,  and  no  anesthesia  will  be  produced. 
It    is    important   to   bear    in   mind    that   when   this 


THORAX    AND   ABDOMEN. 


149 


accident    happens,    the    patient    turns    pale   and    ex- 
periences   nausea. 

(b)  Penetration     into     the     pleura     will     cause 


Fig.  109. — Direction  of  the  lumbar  nerves  after  their  emerg- 
ence from  the  conjugate  foramina.  (Pauchet.)  To  reach 
these  nerves,  the  needle  is  inserted  at  a  distance  of  3  centi- 
meters outside  of  the  spinous  process.  In  the  case  of  the  in- 
tercostals,  at  a  distance  of  3>4  centimeters,  with  the  needle 
close  to  the  low^er  border  of  the  rib,  one  reaches  the  nerve 
numbered  one  less  than  the  spinous  process  serving  as  land- 
mark. In  the  case  of  the  lumbar  nerves,  the  needle,  introduced 
at  the  level  of  the  spinous  process,  will  pass  above  the  upper 
border  of  the  corresponding  transverse  process  and  come  in 
contact  with  the  nerve  of  the  same  number. 


the  patient  to  cough.  The  needle  should  be  with- 
drawn and  inclined  slightly  outward.  This  acci- 
dent,  likewise,    presents   the   disadvantage   that   the 


150 


REGIONAL   ANESTHESIA. 


anesthetic  is  absorbed  without  producing  anesthe- 
sia. To  obviate  it,  one  should  avoid  introducing 
the    needle    more    than    i    centimeter    after    having 


Ul.L., 


,J~^ ? 


Fig.  110. — Paravertebral  injection  of  the  dorsal  and  lumbar 
region.  {Pauchet.)  The  needle  enters  at  a  point  3^  centi- 
meters outside  of  the  dorsal  spinous  process.  Reaching  the 
lower  border  of  the  rib,  it  then  inclines  slightly  inward,  ad- 
vances 1  centimeter,  and  attains  the  anastomosis  of  the  sympa- 
thetic, thus  anesthetizing  the  viscera. 


passed   the   transverse   process,   or   at   a   distance   of 
3^    centimeter   below  the   rib   itself. 

For  the  Lumbar  Nerves. — The  needle  is  intro- 
duced at  a  distance  of  3  centimeters  from  the 
median  line.  After  the  transverse  process  has 
been  found,  at  a  depth  of  4  to   5   centimeters,   the 


THORAX    AND   ABDOMExN.  151 

superior  border  is  followed  around,  the  point 
pushed  in  for  another  centimeter,  and  the  injec- 
tion  made    (Figs.    109   and    no). 

Dermal  infiltration  is  employed  at  first,  and  a 
straight  band,  corresponding  to  the  roots  to  be 
injected  and  parallel  with  the  median  line,  traced 
on  the  surface  of  the  skin.  The  band  referred 
to  should  be  traced  as  follows: 

A  very  fine,  sharp-pointed  needle  3  to  5  centi- 
meters in  length  is  used.  The  skin  is  marked 
with  a  dermal  pencil  at  a  distance  of  y/2  centi- 
meters from  the  median  line  (it  is  difficult  to 
follow  this  line  exactly  without  deviation  if  there 
is  no  landmark).  A  strip  of  skin  i  centimeter 
wide  is  now  infiltrated  with  the  patient  sitting 
bowed  forward  and  the  shoulders  well  drawn  in 
as  for  spinal  anesthesia,  or  lying  down  on  his 
side. 

This  having  been  accomplished,  the  operator, 
employing  a  needle  6  or  9  centimeters  long — ac- 
cording to  its  strength — begins  injecting  the  nerves. 
The  introduction  of  the  needle  will  be  painless. 
Each  spinous  process  is  sought  w^ith  the  left  in- 
dex finger  (a  difficult  matter  in  stout  people), 
and  at  the  level  of  the  spinous  process  the  needle 
is  introduced  3>^  centimeters  from  the  median 
line  until  it  meets  the  rib  or  transverse  process. 
In  muscular  subjects  the  inexperienced  operator 
must  feel  his  way.  When  the  point  strikes  the 
ril:),  it  should  be  withdrawn,  then  directed  against 
and  past  the  lower  costal  border  until  the  bony 
resistance    disappears.      The    operator    now    contin- 


152  REGIONAL   ANESTHESIA. 

ues  to  push  the  needle  ^  centimeter  beyond  and 
injects  5  to  8  mils  of  the  i  per  cent,  solution,  at 
the  same  time  executing  a  to  and  fro  movement 
in  order  not  to  miss  bathing  the  nerve.  The  in- 
jection having  been  completed,  the  needle  is  al- 
lowed to  remain  in  place  to  serve  as  a  landmark. 
The  operator  then  locates  the  spinous  process  of 
the  next  vertebra  below,  and  at  its  level  and  ex- 
actly below  the  needle  above,  he  introduces  his 
second  needle  and  begins  as  before.  For  the  third 
injection,  the  second  needle  is  left  in  place  as  a 
landmark  and,  if  necessary,  the  first  needle  used 
for    the    injection. 

After  the  injections  are  finished  about  fifteen 
minutes  are  required  for  the  anesthesia  to  take 
full  effect.  The  intercostal  space,  muscles,  pleura, 
sternum,  and  ribs  are  all  rendered  insensible.  The 
skin  anesthesia  begins  one  or  two  interspaces  be- 
low the  first  injection.  Transversely,  it  occupies 
the  intercostal  space;  anteriorly  it  reaches  the 
median  line,  and  posteriorly,  it  often  stops  behind 
the  point  where  the  injections  have  been  made. 
If  the  injections  have  been  practised  at  points  im- 
mediately external  to  the  conjugate  foramen,  the 
posterior  branch  is  also  blocked  and  a  laminectomy 
can  be   effected. 

Sixty  to  80  grams  of  the  i  per  cent,  solution 
suffice  for  the  anesthetization  of  12  nerves.  An 
absolute  anesthesia  of  the  thoracic  wall  is  thus 
obtained  which  extends  both  anteriorly  and  pos- 
teriorly to  the  midline. 


THORAX   AND   ABDOMEN.  153 

For  the  upper  portion  of  the  thorax,  the  func- 
tions of  the  cervical  plexus  must  be  also  inter- 
rupted. A  subcutaneous  band  must  be  infiltrated 
the  length  of  the  clavicle  and  spine  of  the  scap- 
ula. If  the  field  of  operation  involves  the  axilla 
or  the  supraclavicular  fossa,  the  brachial  plexus 
should  be  anesthetized. 

For  thoracic  operations  involving  only  the  ribs 
and  parietes,  there  is  no  objection  to  substituting 
intercostal  anesthesia  for  the  paravertebral  anes- 
thesia, i.e.,  instituting  the  anesthesia  at  a  more 
lateral  point  on  the  course  of  the  intercostal  nerve 
above  the  region  to  be  operated  upon.  The  tech- 
nique  of   this   procedure   will   be  described   later. 

PARACENTESIS   OF   THE   PLEURAL  CAVITY. 

With  a  3-centimeter  needle,  the  course  to  be 
followed  by  the  trocar  passing  in  from  the  skin 
to  the  pleura  is  injected.  A  jA  per  cent,  solution 
proves  sufficient;  such  anesthesia  permits  of  the 
use  of   large  trocars  without  pain. 

THORACOTOMY  FOR  EMPYEMA  WITH 
COSTAL   RESECTION. 

The  operator  is  given  the  choice  between  a 
paravertebral  anesthesia  or  the  less  radical  inter- 
costal or  pericostal  anesthesia,  the  technique  of 
which  is  as   follows : 

Attention  is  directed  to  Fig.  iii,  which  rep- 
resents three  adjacent  ribs.     Upon  the  middle  one, 


154 


REGIONAL   ANESTHESIA. 


the  part  in  black  is  to  be  resected;  there  will 
therefore  be  two  intercostal  spaces  to  anesthetize. 
Four  wheals  are  marked  out  and  through  these 
5  mils  of  the  i  per  cent,  solution  injected  into 
the  thickness  of  the  intercostal  muscles.  The 
needle  point  seeks  the  upper  rib  and  follows  its 
inferior   border    until    it   passes   beyond. 


Fig.  111.— Resection  of  a  rib.  (Sonrdat)  An  injection 
is  made  in  the  adjacent  intercostal  spaces  forward  and  back- 
ward on  tlie  portion  of  rib  to  be  resected,  and  followed  by- 
peripheral    infiltration,    subcutaneously    and    intramuscularly. 


The  muscles  and  subcutaneous  tissue  are  in- 
filtrated with  30  or  40  mils  of  the  >^  per  cent, 
solution  in  the  direction  of  the  arrows.  The  re- 
sulting anesthesia  is  complete;  yet  it  is  well  to 
bear  in  mind  that  the  patient  will  complain  if  any 
traction  is  made  on  the  ribs,  producing  torsion  of 
the  costo-vertebral  ligaments.  The  patient  may 
also  complain  if  he  hears  the  section  of  the  ribs; 
it  is  therefore  well  to  cut  the  ribs  gently  and  to 
stop  the  patient's  ears.  A  little  girl  11  years  of 
ag-e — the  niece  of  a  colleague, — ^upon  whom  we 
did  a   resection  of   3   ribs   for   interlobar   empyema, 


THORAX    AND    ABDOMEN. 


155 


cried  every  time  she  heard  the  cutting  of  a  rib, 
though  she  had  not  complained  once  during  the 
remainder  of  the  operation,  except  during  the  pro- 
duction of  the  dermal  wheals.  A  man  30  3^ears 
of  age  cried  out  when  he  heard  a  costal  cartilage 
fall   into   the  bucket  on  the   floor. 


Fig.  112. — Resection  of  the  costal  cartilages.  Diagram  of 
the  infiltration  for  mobilization  of  the  ribs,  as  for  emphysema. 
The  zone  of  anesthesia  should  be  extended  downward  to  the 
free  border  of  the  ribs  if  it  is  desired  to  remove  a  section  of 
cartilage  to  be  used  for  filling  in  a  bony  gap  in  the  skull  from 
trephining. 


RESECTION  OF  THE  SECOND  TO  THE  FIFTH   COSTAL 
CARTILAGES  FOR  RIGIDITY  OF  THE  THORAX. 

From  the  2d  to  the  5th  interspace  two  rows 
of  wheals  are  made  (Fig.  112) — the  outer  at  the 
external  ends  of  the  cartilages,  the  inner  along 
the    sternum.      Through   each   point    5    mils   of   the 


156 


REGIONAL   ANESTHESIA. 


Fig.  113. — Extensive  pleurotomy  and  costal  resection  for  pleu- 
ral sinus.    Raising  the  flap  of  soft  tissues. 


THORAX  AND  ABDOMEN. 


157 


Fig.  114. — Extensive  pleurotomy  and  costal  resection  for 
pleural  sinus.  (Pauchet.)  The  wound  tamponed  at  the  close 
of  the  operation. 


158  .  EEGIONAL   ANESTHESIA. 

I  per  cent,  solution  are  injected  to  enclose  the 
field  of  operation  in  the  dotted  line,  finishing  with 
50  mils  of  the  ^2  per  cent,  solution.  The  same 
procedure  is  followed  for  operations  involving  the 
pericardium  and  heart,  or  for  subphrenic  abscess 
or  suppurative  costo-chondritis.  When  decortica- 
tion of  the  lung  is  practised  for  a  pleural  sinus, 
it  should  be  remembered  that  in  patients  who 
have  undergone  costal  resections  the  ribs  have  1)e- 
come  welded  together.  Under  these  conditions  it 
is  indispensable  to  employ  paravertebral  anesthe- 
sia, intercostal  infiltration  being  no  longer  possible. 


Operations  upon  the  Sternum. 

Five  mils  of  the  i  per  cent,  solution  are  in- 
jected on  both  sides  in  each  space  close  to  the 
sternum.  The  skin  and  subcutaneous  tissues  at  a 
distance  are  then  infiltrated  with  the  ^  per  cent, 
solution   of   procaine-adrenin. 


THORACOTOMY   FOR  ABSCESS   OF   TPIE   LUNG,   EX- 
TRACTION  OF  FOREIGN   BODIES,  OPENING  OF 
INTERLOBAR  ABSCESS,  REMOVAL  OF 
TUMOR   OF   THE    LUNGS,    ETC. 

A  very  wide  anesthesia  of  the  intercostal  nerves 
at  their  origin  should  be  instituted.  The  operator 
may  either  employ  paravertebral  anesthesia  or  in- 
filtrate the  intercostal  nerves  at  points  5  centi-" 
meters    outside    of    the    line    of    the    spinous    proc- 


THORAX    AND    ABDOMEN. 


159 


Fig.  115. — Wound  made  for  resection  of  two  ribs.     (Pauchet.) 
Interlobar  pleurisy. 


160  REGIONAL   ANESTHESIA. 

esses,  i.e.,  at  the  lateral  border  of  the  mass  of  the 
spinal  muscles.  The  intercostal  spaces  are  more 
easily   found   in   this   situation  than   elsewhere. 

The  operator  traces  a  line  with  a  dermal 
pencil  at  a  distance  of  5  centimeters  from  the 
spinous  processes.  Then,  with  a  very  fine  and 
sharp  needle  6  centimeters  long,  a  band  i  centi- 
meter wide  is  infiltrated  with  the  ^  per  cent, 
solution  along  this  line,  with  the  patient  sitting 
down,  bent  forward,  and  with  the  shoulders 
drawn  inward;  or  lying  down  on  the  side.  Along 
this  line  and  on  a  level  with  each  spinous  process, 
an  injection  is  made  immediately  below  the  cor- 
responding rib.  Paravertebral  anesthesia,  which 
renders  the  lung  insensitive,  is  the  procedure  of 
choice. 

Operations  for  Tumor  of  the  Breast. 

For  benign  operations  on  the  breast,  including 
extirpation  of  adenoma  and  total  extirpation  of 
the  mammary  gland,  a  large  subcutaneous  lozenge,  is 
circumscribed  through  4  or  5  wheals.  Next,  the  sub- 
mammary tissue  is  infiltrated,  thus  completing  an 
absolute  circumferential  anesthesia.  A  large  amount 
of  y^  per  cent,  solution — 100  or  150  mils — is  re- 
quired. Half  of  the  liquid  runs  off  with  the 
blood  during  the  operation.  We  have  injected  as 
much  as  250  mils  without  any  harmful  after-efitects. 


THORAX    AND    ABDOMEN.  161 


REMOVAL   OF   CANCER   OF   THE   BREAST. 

Procaine-adreniii  has  been  used  by  us  several 
times  for  this  purpose,  not  only  in  thin  women, 
but  also  in  fat  women  with  some  contraindication 
to  general  anesthesia,  such  as  renal  insufficiency, 
myocarditis,  etc.  The  results  were  good.  At  times 
inhalation  of  ethyl  chloride  became  necessary,  how- 
ever,   at   the   time   of   dissection   of   the   axilla. 

The    technique    comprises    the    following    steps: 

(a)  Blocking  of  the  brachial  plexus  with  lo  mils 
of  the  I  per  cent,  solution,  injected  from  above 
the  clavicle  or  in  the  axilla.  The  latter  route 
presents  the  added  advantage  of  anesthetizing 
simultaneously     the     surrounding     cellular     tissues. 

(b)  Paravertebral  injection  from  D.  i  to  D.  lo 
with  50  mils  of  i  per  cent,  solution.  (c)  Sub- 
cutaneous injection  of  ico  mils  of  ^  per  cent, 
procaine-adrenin,  starting  at  the  acromion,  follow- 
ing the  clavicle  to  block  the  cervical  plexus,  then 
the  midline  of  the  thorax,  the  lower  border  of  the 
thorax,  and  finally  passing  backward  to  the  promi- 
nence of  the  latissimus  dorsi.  In  the  case  of  an 
obese  woman,  we  employ  ordinarily  150  mils  of 
procaine-adrenin;  large  amounts  of  the  fluid  run 
off,  however,  during  the  operation.  By  the  use 
of  hypotonic  saline  solution  the  dose  of  procaine- 
adrenin  injected  may  be  reduced. 


11 


162  REGIONAL   ANESTHESIA. 


Operations   in   the  Axilla. 

Theoretically,  the  brachial  plexus  may  be  blocked 
by  supraclavicular  injection  and  the  first  5  inter- 
costal nerves  by  paravertebral  injection.  To  the 
inexperienced  operator  we  advise,  however,  merely 
an  infiltration  of  the  axilla,  as  explained  later. 


ABDOMEN. 

If  the  operative  procedure  required  consists 
merely  of  incising  an  anterior  peritoneal  abscess, 
appendicular  or  otherwise,  simple  infiltration  of 
the  wall  by  Reclus's  method  is  sufficient.  For  an 
operation  involving  prolonged  maneuvers,  such  as 
exploration  of  the  abdomen,  recourse  must  be  had 
to  anesthesia  of  the  wall  at  a  distance  and  to 
paravertebral  anesthesia. 

(A)  Infiltration  of  the  wall  at  a  distance  from 
the  field  of  operation  results  in  a  block  of  the 
nerve  supply  and  yields  a  perfect  anesthesia,  but 
one  which  is  only  parietal.  While  the  viscera  are 
not  reached,  the  incision,-  separation,  and  suture  of 
the  abdominal  wall  are  rendered  painless.  The 
viscera,  furthermore,  are  only  slightly  sensitive  pro- 
vided no  traction  be  exerted.  This  semi-sensibil- 
ity on  their  part  permits  of  the  performance  of 
gastro-enterostomies  and  intestinal  resections  under 
parietal   infiltration,  without  shock. 

In  some  instances,  after  the  abdomen  has  been 
opened,   the   anesthesia   can   be   continued   by   direct 


THORAX    AND    ABDOMEN.  163 

injection  of  quinine  and  urea  solution  into  the 
mesentery.  One  mil  of  a  i  per  cent,  solution  may 
be  injected  into  the  meso-appendix  for  appendicec- 
tomy,  and  a  few  drops  of  a  i  per  cent,  solution 
in  the  vicinity  of  each  omental  vessel  for  resection 
of  the  omentum.  Such  injections  between  the  two 
layers  of  the  peritoneum,  along  the  vessels,  gives 
a  perfect  anesthesia;  but  it  is  only  practicable  in 
certain  special  cases.  For  resection  of  the  stom- 
ach, for  instance,  we  anesthetize  the  nerves  of 
the  organ  by  infiltrating  the  peritoneum  in  the 
vicinity  of  the  coronary  artery,  the  pylorus,  and 
the  two  gastric  omenta.  Only  very  gentle  handling  is, 
however,  permissible,  or  during  painful  manipula- 
tions some  drops  of  ethyl  chloride,  chloroform,  or 
ether  will  have  to  be  administered.  The  anesthe- 
sia is  often  incomplete,  demanding  either  some 
mental  encouragement  of  the  patient  or  a  few 
whiffs  of  an  anesthetic.  In  three-fourths  of  the 
cases  this  method  proves  efifective,  and  permits  of 
the  performance  of  severe  operations  without 
shock. 

{B)  Paravertebral  anesthesia,  on  the  other  hand, 
gives  absolute  anesthesia,  at  least  on  the  side  of 
the  body  on  which  it  is  made.  It  must  be  bi- 
lateral if  the  viscera  are  in  or  pass  beyond  the 
median  line.  A  choledochotomy,  or  removal  of  a 
tumor  of  the  cecum,  can  be  perfectly  performed 
under  right-sided  paravertebral  anesthesia.  For  a 
nephrectomy,  or  the  removal  of  a  circumscribed 
tumor  of  the  colon,  unilateral  anesthesia  is  like- 
wise  sufficient.     To   operate  on   the   stomach    (gas- 


164  REGIONAL   ANESTHESIA. 

trectomy)  or  pancreas,  however,  both  sides  must 
be   injected. 

The  operator  may  manipulate  throughout  the 
abdomen  by  infihrating  from  the  5th  intercostal 
to  the  2d  lumbar  nerve  on  both  sides.  The  re- 
quired 22  injections  are,  however,  distressing  and 
involve  the  use  of  a  large  dose  of  procaine- 
adrenin. 

On  several  occasions  we  have  made  a  trans- 
verse bilateral  incision  after  paravertebral  infiltra- 
tion of  only  6  nerves  on  each  side;  the  anesthe- 
sia was  perfect.  For  the  stomach,  we  do  not  em- 
ploy this  procedure  systematically  because  we  pre- 
fer the  long  vertical  incision,  and  we  confine  the 
anesthesia  to  simple  infiltration  of  the  abdominal 
wall  with  injection  of  cjuinine  and  urea  in  the 
mesentery.  The  two  forms  of  anesthesia  may  be 
combined  by  (a)  making  a  double  paravertebral 
injection  of  the  D.  6,  7,  8,  and  9  nerves, — 8  in- 
jections all  told,  4  on  each  side — to  anesthetize 
the  stomach  and  epigastric  wall,  and  {b)  infiltrat- 
ing in  the  midline  below  the  umbilicus  for  a  dis- 
tance of  5  to  6  centimeters  with  a  weak  anes- 
thetic solution. 

Practice  with  paravertebral  injections  induces 
the  surgeon  to  employ  them  more  and  more  fre- 
ciuently  in  his  work,  as  they  are  particularly 
adapted  for  abdominal  surgery.  The  more  experi- 
enced the  surgeon  in  the  technique,  the  more  in- 
clined he  becomes  to  substitute  the  procedure  for 
parietal  infiltration.  I  shall  present,  however,  with 
reference    to    each    operation,    the    details    of    the 


THORAX    AND    ABDOMEN. 


165 


latter,    pointing    out    at    the    same    time  the  precau- 
tions to   be   taken   during   the   course   of   the   opera- 


tion under  regional  anesthesia. 


Operations  upon  tpie  Stomach. 

GASTROSTOMY  AND  GASTRO-ENTEROSTOMY. 

Three    dermal    wheals    are    infiltrated, — one    at 
the   level   of   the   ensiform    cartilage,    the   others    at 


Fig.     116. — Infiltration     for    supraumbilical    laparotomy.      Six 
wheals.     For  gastrectomy  and  gastroenterostomy. 


the  free  borders  of  the  ribs  lo  or  12  centimeters 
from  the  first.  The  subcutaneous  cellular  tissues 
and  ijortions  of  muscle  attached  to  the  costal  border 
are    infiltrated    successively    in    order    to    block    the 


166  REGIONAL   ANESTHESIA. 

nerve  filaments  that  supply  the  midline  over  two- 
thirds  of  its  length  above  the  umbilicus.  The  ab- 
dominal wall  can  then  be  immediately  incised, 
either  to  the  right  or  left  of  this  line.  Next,  the 
skin  and  muscles  over  the  free  borders  of  the  ribs 
on  the  left  side  are  infiltrated  for  a  distance  of 
lo,    12,   or    15    centimeters. 

Manipulations  of  the  stomach  being  but  slightly 
painful,  all  complementary  anesthesia  is  useless. 
The  infiltration  requires  from  100  to  120  mils  of 
the  weak  solution  to  completely  relax  the  abdom- 
inal muscles.  Such  anesthesia  is  sufficient  also  for 
gastro-enterostomy.  We  inject  previously,  how- 
ever, pantopon  or  scopolamine-morphine. 


GASTRECTOMY. 

The  same  paracostal  incision  is  made,  but  in  a 
bilateral  form  (Fig.  117).  The  operation  is  rather 
more  painful  owing  to  the  extensive  and  pro- 
longed manipulation  of  the  stomach  involved.  If 
a  complete  anesthesia  is  considered  advisable,  it 
is  necessary  either  to  institute  a  double  paraver- 
tebral anesthesia  (6  nerves  on  each  side)  or  after 
the  abdomen  is  opened  to  give  some  whiffs  of 
chloroform  or  infiltrate  the  mesentery  with  qui- 
nine and  urea.  It  wall  be  sufficient  to  chloroform 
the  patient  slightly  during  the  liberation  and  ex- 
ploration. The  suturing  and  cutting  of  the  intes- 
tines   are   painless.      The    mental    condition    of    the 


THORAX    AND    ABDOMEN. 


167 


patient  is  all-important.  There  are  great  contrasts 
between  individual  temperaments.  Some  patients  do 
not  utter  a  word  during  the  operation,  while  others 
cry  out  for  an  anesthetic  and  never  cease  com- 
plaining. 


Fig.  117. — Infiltration  for  high  laparotomy.  (Sourdat.) 
Yields  a  larger  area  of  anesthesia  than  the  preceding.  For 
gastro-enterostomy;  operations  on  the  gall-bladder  and  colon. 


Median  Hypogastric  Incision. 

We  seldom  practice  abdomino-pelvic  operations 
under  local  anesthesia.  Yet  the  evacuation  of  a 
tuberculous  ascites  or  the  removal  of  a  movable 
tumor  of  the  ovary  may  be  very  easily  effected 
with  this  procedure.  The  pedicle  should  be  in- 
filtrated with  a   I  per  cent,  solution  of  quinine  and 


168  REGIONAL   ANESTHESIA. 

urea  without  injecting  the  viscera;  it  can  then 
be  easily  crushed  and  tied  without  pain. 

Cesarean  section  can  readily  be  practised  under 
infiltration  anesthesia.  A  lozenge-shaped  area 
three  finger-breadths  wide,  in  the  median  line,  is 
infiltrated  so  as  to  block  the  musculo-cutaneous 
endings  of  the  abdominal  nerves.  Opening  of  the 
abdomen  is  thus  rendered  painless,  the  peritoneum 
having  been  anesthetized  by  the  blocking  of  the 
parietal  nerves.  The  uterus  is  almost  insensitive; 
yet  it  is  well  to  anesthetize  it  with  quinine  and 
urea,  infiltrating  a  strip  of  uterine  tissue  on  each 
side  of  the  intended  uterine  section  at  a  distance 
of  two  or  three  finger-breadths  from  the  median 
line.     There  is  little  bleeding. 

In  hysterectomy,  as  for  cancer,  fibroids,  or  sal- 
pingitis, we  prefer  lumbar  spinal  anesthesia,  but 
bilateral  paravertebral  anesthesia  will  also  serve 
the  purpose.  One  must  inject  twelve  pairs  on 
each  side, — the  six  lower  intercostals,  three  lum- 
bar, and  three  sacral.  For  the  lesser  operations, 
such  as  hysteropexy,  removal  of  ovarian  cysts, 
etc.,    we   prefer    a   brief    general    anesthesia. 

Hypogastric  anesthesia  for  cystotomy  is  insti- 
tuted through  two  wheals,  the  one  at  the  umbili- 
cus and  the  other  at  the  pubis.  Through  these 
one  infiltrates,  not  in  the  median  line,  but  on 
either  side,  the  skin  and  muscles.  The  peritoneum 
is  itself  anesthetized.  The  muscles  must  be  anes- 
thetized, and  not  the  linea  alba, — that  they  may  be 
separated  without  pain. 


THORAX    AND    ABDOMEN. 


169 


Operations  in  the  Iliac  Fossa, 
ileocecal  region. 

Here  it  is  well  to  institute  a  sufficiently  low 
paravertebral  anesthesia,  i.e.,  one  involving  the 
last  two  intercostal  nerves  and  the  first  three  lum- 
bar. If,  owing  to  the  technical  difficulties,  the 
operator    prefers    to    block    the    nerves    nearer  the 


I   I 
/    I 

4 


:^ 


Fig.  118. — Infiltration  for  operative  work  in  the  ileocecal 
region.  (Pauchet.)  A  diamond-shaped  figure  under  the  skin 
and  in  the  muscles,  circumscribing  the  future  incision,  should 
be  infiltrated.    P'or  appendicitis ;  ileocecal  resection. 


field  of  operation,  he  can  have  recourse  to  infiltra- 
tion of  the  abdominal  wall  in  the  following  man- 
ner (see  Fig.  ii8  and  the  subsequent  illustrations). 

Four  dermal  wheals  are  made,  in  the  form 
of  a  lozenge.  The  two  lateral  wheals  are  placed, 
the  one  inside  the  anterior  superior  spine  of  the 
ilium,  the  other,  two  or  three  finger-breadths  from 


170 


REGIONAL   ANESTHESIA. 


the  middle  line.  The  superior  and  inferior  wheals 
are  situated,  the  one  at  a  distance  of  three  finger- 
breadths  from  the  first,  the  other,  three  finger- 
breadths  from  the  second.  The  muscular  layers 
should  be  infiltrated  only  at  the  two  upper  sides 
of  the  lozenge;  over  the  two  lower  sides  only  the 


Fig.  119. — Deep  "fan-shaped"  injection  to  infiltrate  the  mus- 
cular mass  at  the  point  of  emergence  of  the  nerves  of  the  in- 
guino-crural  region.  (Pauchet.)  (D)  Rectus  abdominis.  (B) 
Ilio-psoas.  (A)  Gluteus.  (C)  Iliac  bone.  (£)  Three  direc- 
tions of  the  needle:  the  first  perpendicular  to  the  skin,  toward 
the  subserous  cellular  tissue;  the  second,  parallel  to  the  skin, 
beneath  the  aponeurosis;  the  third,  intermediate,  oblique  in  the 
intermuscular  space,  where  the  nerves  are  found.  (1)  Dermal 
wheal. 


subcutaneous  cellular  tissue  is  to  be  infiltrated. 
The  infiltration  of  the  muscles  produces  not  only 
anesthesia  of  these  structures,  but  also  anesthesia 
of  the  peritoneum. 

With  this  procedure  we  have  performed  the 
following  operations:  Cecostomy,  resection  of  the 
ileocecal  segment  for  cancer  or  tuberculosis,  ap- 
pendicectomy,  closing  of  intestinal  fistula,  and  en- 
terostomy. 


THORAX    AND    ABDOMEN. 


171 


The  incision  in  the  abdominal  wall  and  the 
separation  of  the  wound  margins  are  painless,  but 
it  is  necessary  to  infiltrate  the  meso-appendix  or 
the  end  of  the  mesentery  with  quinine  and  urea 
if  section  of  this  last  structure  is  indicated. 


Fig.  120.— Same  as  the  preceding.  (Pauchet.)  Horizontal 
section  at  the  level  of  the  iliac  spine.  (1)  Rectus  abdominis. 
(2)  and  (3)  Ilio-hypogastric  and  ilio-inguinal  nerves,  situated 
at  this  point  between  the  internal  oblique  and  transversalis 
muscles.  (4)  Genito-crural  nerve.  (5)  Iliac  bone.  (6) 
Parietal  peritoneum.  (£)  Wheal  situated  two  finger-breadths 
within  the  iliac  spine  and  through  which  the  fan-shaped  injec- 
tion is  made. 


On  the  whole,  I  desire  to  emphasize  the  fact 
that  paravertebral  anesthesia  for  the  viscera  is 
rather  to  be  recommended.  The  operation  for  ap- 
pendicitis may  almost  always  be  performed  under 
it.  We  have  operated  upon  children  of  8  years, 
and  with  greater  facility  children  of  lo  to  15 
years,   without   general   anesthesia. 


172 


REGIONAL   ANESTHESIA. 


Fig.  121. — Deep,  "fan-shaped"  injection  above  the  anterior 
superior  iliac  spine.  (Pauchct  and  Sonrdat.)  To  anesthetize 
the  wall  of  the  iliac  fossa,  for  appendectomy,  cecostomy,  ileo- 
cecal resection.  The  figure  shows  the  manner  of  direct  injec- 
tion, perpendicular  to  the  plane  of  the  wall. 


THORAX    AND    ABDOMEN. 


173 


Fig.  122. — Oblique  injection  upward.     (Pauchet  and  Sourdat.) 
Note  the  direction  imparted  to  the  syringe  and  needle. 


174 


REGIONAL   ANESTHESIA. 


Fig.  123. — Same  injection  directed  obliquely  downward. 
(Pauchet  and  Sourdat.) 


THORAX    AND    ABDOMEN. 


175 


IliD-ingainal 
Ilin-hypagastric 

GEnito- crural 


Fig 
chei.) 
gray). 


124. — Paracostal  anesthesia — costo-iliac  and  para-iliac.  {Pau- 
Anesthesia  of  the  entire  abdominal  wall  (anesthetized  zone  in 
To  the  right  are  seen  the  intercostal  filaments  supplying  the 
abdominal  wall,  and  lower  down  the  ilio-hypogastric  and  ilio-inguinal 
nerves,  and  the  genito-crural  (vertically  directed).  To  the  left  of  the 
figure,  A,  B,  and  C  show  the  paracostal  infiltration  of  a  portion  of 
muscle  and  of  the  skin  (stomach,  liver,  and  duodenum).  C,  D,  anes- 
thesia of  the  abdominal  wall  for  the  ascending  colon.  E.  F.  useful  for 
cecal  or  appendicular  operations  and  for  the  radical  cure  of  inguinal 
hernia. 


176 


REGIONAL   ANESTHESIA. 


Fig.   125. — Appendicitis.     (Pauchet  and  Sourdat.) 
of  the  abdominal  wall. 


Incision 


THORAX    AND    ABDOMEN. 


177' 


Fig.    126. — Appendicitis.      (Pauchet   and   Sourdat.)      The   ap- 
pendix and  cecum  are  Brought  to  the  exterior. 


12 


178 


REGIONAL   ANESTHESIA. 


Fig.  127. — Anesthesia  of  the  meso-appendix.  (Pauchet.) 
Interval  operation.  The  needle  is  inserted  between  the  two 
layers  of  the  meso-appendix,  in  the  vicinity  of  the  appendicular 
artery.  One  mil  of  3^2  per  cent,  quinine  and  urea  hydrochloride 
solution  is  injected.  The  operator  may  then  tie  and  divide, 
without  pain,  the  meso-appendix  and  the  appendix  itself. 


THORAX    AND    ABDOMEN. 


179 


Fig.  128. — Quinine  and  urea  anesthesia  of  the  mesenteric 
nerves  before  intestinal  resection.  (Pauchef.)  The  needle  is 
inserted  in  the  first  layer  of  the  mesentery,  and  1  or  2^^  mils 
of  i/^  per  cent,  quinine  and  urea  solution  injected.  The  oper- 
ator is  enabled  immediately  to  cut  the  vascular  pedicle  and  re- 
sect the  intestine  without  pain.  In  this  instance,  it  is  the 
transverse  colon. 


180 


REGIONAL   ANESTHESIA. 


Fig.  129. — Pylorectomy  for  callous  ulcer.  (Pauchet.)  First 
step:  Exploration  of  the  abdomen.  (Patient  from  the  La  Pitie 
Hospital). 


THORAX    AND    ABDOMEN. 


181 


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Fig.  130. — Pylorectomy  for  callous  ulcer.  (Pauchet.)  Pyloric  seg- 
ment resected.  The  canal  has  been  incised  lengthwise  along  the  greater 
curvature,  then  spread  out.  Lower  down,  the  great  omentum  is  seen 
attached  to  the  greater  curvature  by  an  inflamed  lymph-gland.  The 
operative  mortality  is  8  per  cent. 


182 


REGIONAL  ANESTHESIA. 


Fig.    131. — Continent   jejunostomy.      (Pauchet.)      For  a  large 
cancer  of  the  stomach.     (Patient  from  La  Pitie  Hospital). 


Fig.  132. — Artificial  anus  due  to  wound  of  the  intestine. 
(Pauchet.)  Military  wound  from  La  Pitie  Hospital  (shell 
splinter).    Circular  enterorrhaphy. 


THORAX    AND    ABDOMEN. 


183 


Fig.  133. — Ileocecal  segment  invaded  by  cicatricial  tuberculosis. 
(Pauchet.)  To  the  right  the  end  of  the  small  intestine  may  be  recog- 
nized. The  cecum  has  become  transformed  into  a  fibrous  mass,  with 
a  small,  hardly  perceptible,  mucous  canal.     (La  Pitie  Hospital.) 


184 


REGIONAL    ANESTHESIA. 


Fig.  134. — Partial  gastrectomy  for  saddle  ulcer  of  the  lesser  curva- 
ture. (Pauchet.)  First  stage  of  the  operation :  Separation  of  the 
omentum  by  means  of  the  scalpel.  The  assistant  holds  the  transverse 
colon  Mrith  the  left  hand;  the  operator  holds  the  scalpel  with  his  right 
hand  and  with  the  left  the  omentum  is  separated  from  the  transverse 
colon  for  examination  of  the  posterior  surface  of  the  stomach.  Mor- 
tality 8  per  cent. 


THORAX    AND    ABDOMEN. 


185 


Fig.  135. — Specimen  from  the  preceding  patient.  (Paiichet.)  Mid- 
dle segment  of  the  stomach,  showing  a  saddle  ulcer  of  the  lesser  curva- 
ture. The  resected  segment  has  been  laid  open  along  the  greater 
curvature,  to  which  the  omentum  is  attached  below.  The  center  of  the 
figure,  where  the  ulcer  is  found,  corresponds  to  the  middle  of  the 
lesser  curvature. 


186 


•REGIONAL    ANESTHESIA. 


Umbilical   Hernia. 

Umbilical  hernias  and  hernias  of  the  linea  alba 
are  operated  under  lateral  infiltration  of  the  mus- 
cles, in  the  same  manner  as  for  laparotomy.  The 
operator    infiltrates    successively    the    skin    and    the 


Fig.  136. — Anesthesia  for  radical  cure  of  a  reducible  um- 
bilical hernia.  (Pauchet.)  Through  the  wheals  a  ring  of  in- 
filtration is  made,  following  the  dotted  line,  tmder  the  skin 
and  in  the  thickness  of  the  muscles. 


muscles  down  to  the  subserous  cellular  tissue  with 
a  weak  solution.  Pauchet,  in  19 14,  operated  at 
Amiens  on  an  obese  woman  with  a  strangulated 
hernia  in  the  median  line,  of  the  size  of  an  adult's 
head  and  containing  1.50  meters  of  gangrenous 
intestine.     The  patient  complained  somewhat  when 


THORAX    AND    ABDOMEN. 


187 


the  mesentery  was  ligated,  but  it  did  not  become 
necessary  to  have  her  inhale  any  chloroform.  Two 
hundred  and  fifty  mils  of  a  3^  per  cent,  solution 
were   employed. 

In    an    extremely    obese    woman    with    a    simple 
umbilical  hernia,   Pauchet  injected  as  much  as   300 


Fig_  137. — Location  of  the  wheals  and  the  proper  direction 
of  injection  for  anesthetization  in  irreducible  umbilical  hernia. 
(Pauchet.) 

mils  of  the  weak  solution.  Part  of  the  fluid  es- 
caped, however,  during  the  operation.  In  making 
these  injections,  12-centimeter  needles  were  em- 
ployed. 

For  all  these  operations,  the  procedure  is  al- 
ways the  same.  A  lozenge-shaped  wall  of  infil- 
tration around  the  umbilicus  is  established.  Through 
four    wheals    all    of    the    subcutaneous    tissue    and 


188 


REGIONAL   ANESTHESIA. 


muscles  are  infiltrated,  following  the  lines  that 
form  the  lozenge.  In  cases  of  umbilical  hernia 
and  post-operative  eventration,  injection  of  quinine 
and   urea   into   the   omentum,   about   the   vessels,   is 


Fig.  138. — Injection  for  irreducible  umbilical  hernia. 
(Pauchet.)  The  infiltration  is  conducted  at  a  distance  from 
the  ring  and  through  the  entire  thickness  of  the  wall. 


an  important  preliminary  to  resection  of  the  omen- 
tal membrane,  which  under  this  treatment  becomes 
absolutely  insensitive. 


Inguinal  Hernia. 

The  operation  for  inguinal  hernia  is  without 
doubt,  of  all  operations,  that  in  which  regional 
anesthesia  gives  the  greatest  satisfaction,  no  mat- 
ter how  voluminous  the  hernia  may  be.  That  it 
is  indicated  is  due  to  three  factors:  (i)  The 
disease  itself  is  hardly  more  dangerous  than  gen- 
eral anesthesia;  the  latter  may  give  rise  to  a  bron- 
chitis   that    is    prejudicial    to    consolidation    at    the 


THORAX    AND    ABDOMEN. 


189 


points  of  suture;  (2)  the  resultant  vomiting  has 
the  same  tendency;  (3)  regional  anesthesia,  which, 
it  must  be  recognized,  is  imperfect  for  certain 
operations,    shows    its    utility    for    the    radical    cure 


Fig.  139. — Nerve  supply  of  the  inguinal  region  (diagram- 
matic). (Pauchet.)  Points  of  emergence  of  the  genito-crural, 
ilio-hypogastric,  ilio-inguinal,  and  of  an  anterior  branch  of  the 
12th  intercostal.  For  anesthesia  of  the  inguino-crural  region 
they  should  be  reached  here  by  injection.  The  needle  should 
be  introduced  within  the  anterior  superior  iliac  spine. 


of  inguinal  hernia  when  properly  employed,  and 
the  technique  for  this  operation  is  very  simple. 
In  April,  19 16,  at  the  La  Pitie  Hospital  we  op- 
erated on  an  inguinal  hernia  of  the  size  of  a 
large  adult's  head,   without   the   slightest   pain. 


190  REGIONAL   ANESTHESIA. 

Paravertebral  anesthesia  will  yield  a  perfect 
anesthesia  at  a  distance  and  seems  to  us  the  pro- 
cedure of  election.  No  matter  how  large  the  her- 
nia, it  will  be  sufficient  to  inject  the  two  lower 
intercostal  and  upper  three  or  four  lumbar  nerves. 
Yet  the  great  majority  of  surgeons  prefer  anes- 
thesia by  localized  infiltration  of  the  nerves  of 
the  region,  the  technique  of  which  is  as  follows: 

Figures  139  and  124  show  the  innervation  of 
the  groin  and  of  the  crural  region  respectively. 
The  genital  branch  of  the  genito-crural  reaches 
the  spermatic  cord  through  the  internal  ring  and 
accompanies  it  in  the  canal  and  in  the  skin  of 
the  scrotum  or  of  the  labia  majora.  The  ilio-in- 
guinal  is  situated  above  the  iliac  spine,  between 
the  oblique  muscles;  it  passes  under  the  aponeu- 
rosis of  the  external  oblique,  emerges  from  the 
inguinal  canal  upon  the  anterior  surface  of  the 
cord  and  of  the  sac,  and  ends  in  the  skin  of  the 
scrotum  or  mons  veneris.  The  ilio-hypogastric, 
parallel  to  the  preceding  and  slightly  higher  up, 
makes  its  way  between  the  two  oblique  muscles; 
reaching  the  inguinal  region,  it  passes  under  the 
aponeurosis  of  the  external  oblique,  crosses  through 
the  anterior  layer  of  the  sheath  of  the  rectus,  and 
ends  in  the  skin  of  the  groin.  These  three  nerves 
anastomose  with  each  other.  It  is  necessary, 
therefore,  that  all  three  be  anesthetized.  They  are 
all  to  be  found  grouped  together  in  a  space  of  2 
or  3  finger-breadths  within  and  above  the  iliac 
spine. 


THORAX    AND    ABDOMEN. 


191 


REDUCIBLE  INGUINAL  HERNIA. 

Two  wheals  are  made,  the  first  two  finger- 
breadths  within  the  anterior  superior  iHac  spine 
and   the   second  corresponding  to  the  pubis   at  the 


Fig.  140. — Anesthesia  for  irreducible  inguinal  hernia. 
(Sourdat.)  Location  of  the  two  wheals.  The  arrows  show 
the  direction  of  the  deep  injections.  The  unbroken  line  out- 
lines the  subcutaneous  infiltration. 


level  of  the  external  abdominal  ring.  Through 
wheal  No.  i,  infiltration  is  executed  according  to 
the  scheme  shown  by  the  arrows  in  Figs.  119 
and  120.  All  the  muscular  layers  situated  be- 
tween point    I    and  the  ilium   are   infiltrated,   using 


REGIONAL   ANESTHESIA. 


Fig.  141. — Same  as  the  preceding.  (Sourdat.)  A  wheal 
is  made  two  finger-breadths  within  the  anterior  superior  iliac 
spine.  The  second  wheal  is  made  above  the  horizontal  ramus 
of  the  pubis.  The  black  line  shows  the  subcutaneous  infil- 
tration. 


THORAX    AND    ABDOMEN.  193 

20  mils  of  a  I  per  cent,  solution.  A  9-centimeter 
needle  is  introduced  perpendicularly,  passing  through 
the  aponeurosis  of  the  external  oblique,  the  inter- 
nal oblique,  and  the  transversalis  muscle.  It  is 
then  inserted  so  as  to  cover  a  fan-shaped  sector, 
and  more  and  more  obliquely  toward  the  spine 
of  the  ilium.  The  muscular  layer  here  is  very 
thick.  This  injection  reaches  the  ilio-hypogastric 
and  ilio-inguinal  nerves.  Through  point  i,  it  is 
necessary  to  infiltrate  anew  under  the  aponeurosis 
of  the  external  oblique  a  strip  ending  at  two 
points  situated,  respectively,  within  and  externally 
to  the  hernial  ring,  using  approximately  20  mils  of 
the  weak  solution.  Through  wheal  No.  2,  10  mils 
of  the  solution  are  injected  in  a  fan-shaped  area 
to  the  line  of  the  cord;  the  needle  should  strike 
the  pubic  bone.  Through  the  same  point,  10  mils 
are  next  injected  in  the  inguinal  canal  itself 
along  the  cord.  Finally,  subcutaneous  infiltration 
is  conducted  following  the  lozenge-shaped  figure 
shown  in  the  ihustration,  approximately  100  mils 
of  the  weak  solution — ^  per  cent. — being  used 
altogether    (Figs.    140  and   141). 


IRREDUCIBLE  OR   STRANGULATED   INGUINAL 
HERNIA. 

Four  wheals  are  made  as  indicated  in  Fig. 
142.  Through  wheal  No.  i  one  injects,  as  before, 
against  the  iliac  bone,  and  continues  toward 
wheals   Nos.   2  and  3,   injecting  under  the  aponeu- 

13 


194 


REGIONAL   ANESTHESIA. 


rosis.  Next,  two  deep  injections  are  made  through 
points  2  and  3.  While  the  left  hand  pushes 
laterally  inward  and  outward  the  hernia  mass,  the 
needle   is   inserted  as   far   as   the  pubis,   under   the 


Fig.  .142. — Lines  of  infiltration  for  inguinal  hernia.     (Sourdat.) 
For  irreducible  or  strangulated  hernia. 


hernia,  and  injection  made  deeply  in  the  canal 
through  points  2  and  3  along  the  neck  of  the 
sac.  Finally,  a  subcutaneous  injection  between  the 
points  1-2-3  ^^^  2-3-4,  is  made.  For  a  large 
hernia  150  mils  of  the  weak  solution  may  be  used. 


THORAX    AND    ABDOMEN.  195 

We  prefer  in  such  cases  the  paravertebral  form  of 
anesthesia,  which  deals  with  the  nerves  supplying 
the  cord.  The  procedure  just  described,  however, 
will  likewise  give  satisfaction  (Figs.   142  and  143). 


Fig.  143. — Anesthesia  of  the  scrotum  for  irreducible  her- 
nia. (Sourdat.)  Subcutaneous  infiltration  of  the  root  cf  the 
scrotum  through  a  crown  of  wheals. 


Femoral  Hernia. 

The  nerve  supply  in  femoral  hernias  is  essen- 
tially that  of  the  inguinal  region.  The  anesthetic 
])rocedure,    therefore,    is   almost   the    same: 


196 


REGIONAL   ANESTHESIA. 


Four  dermal  wheals  are  made.  Point  i  occu- 
pies the  same  place  as  in  inguinal  hernia,  viz., 
two  finger-breadths  within  the  anterior  superior 
iliac   spine.      Points   2   and   3   are  within   and  out- 


Fig.  144. — Reducible  femoral  hernia.  The  deep  injections 
(arrows)  an<i  subcutaneous  circuminfiltration  are  made  through 
wheals  1,  2,  3,  and  4. 


side  of  the  hernia,  respectively,  and  at  both  ends 
of  the  intended  femoral  incision,  parallel  to  the 
femoral  arch.  Point  4  is  below  the  hernial  mass. 
One  starts  with  the  intramuscular  injections  at 
point  I.  Through  this  one  injects  under  the 
aponeurosis  up  to  and  outside  of  the  neck.    Then, 


THORAX    AND    ABDOMEN. 


197 


Fig.  145. — Irreducible  femoral  hernia.  (Pauchet.)  A  fan- 
shaped  intramuscular  injection  is  made  through  point  A. 
Infiltration  of  a  subcutaneous  band  surrounding  the  hernial 
tumor  and  neck  is  conducted  through  points  A,  B,  C,  and  D. 


Fig.  146. — Anesthesia  of  the  hernial  sac  and  testicle  by 
infiltration  of  the  cord.  Injection  of  the  cord  in  the  inguinal 
canal. 


198  REGIONAL  ANESTHESIA. 

under  the  femoral  arch  through  point  4,  10  mils 
of  the  solution  are  infiltrated  around  the  neck,  and 
very  close  to  it.  Finally,  subcutaneous  infiltration 
is  effected.  The  femoral  arch  is  anesthetized  by 
this  procedure.  If  it  be  necessary  to  combine  an 
inguinal  incision  with  the  high  femoral  incision, 
the  anesthesia  will  be  sufficient  for  the  purpose. 
We  have  never  been  compelled  to  give  ethyl  chlo- 
ride to  the  patient  during  the  liberation  of  the 
intestine.  When,  however,  in  a  stout  patient,  we 
contemplated  radical  cure  of  a  femoral  hernia 
through  the  inguinal  route,  the  patient  complained 
somewhat  while  we  were  working  deeply,  showing 
that  the  anesthesia  had  been  incorrectly  instituted. 

Operations  upon  the  Kidney. 

Nephrectoiny  is  another  operation  for  which 
regional  anesthesia  is  indicated.  This  method 
saves  the  renal  tissue  in  the  same  way  as  it  does 
the  hepatic.  The  anesthesia,  moreover,  is  com- 
plete. The  lateral  position  of  the  subject  can  be 
maintained  without  the  help  of  an  assistant,  the 
patient's  voluntary  aid  being  sufficient.  Decortica- 
tion of  the  kidney  and  the  ligation  of  the  pedicle 
are  painless.  We  employ  unilateral  paravertebral 
injection  of  the  six  lower  intercostal  and  of  two 
lumbar  nerves.  When  once  familiar  with  the 
technique,  one  no  longer  finds  it  necessary  to 
have  the  patient  inhale  any  additional  anesthetic 
at  the  time  of  decortication  of  the  kidney. 


THORAX   AND   ABDOMEN.  199 


Operations   upon   the   Biliary   Passages. 

It  is  advantageous  to  perform  these  without 
ether  or  chloroform,  the  harmful  action  of  which 
upon  the  hepatic  cells  is  well  known.  Our  first 
operations  under  paravertebral  anesthesia  were 
done  upon  patients  suffering  from  chronic  jaun- 
dice,— of  two  months'  standing  in  one  instance 
(pancreatic  tumor)  and  in  another,  six  months  (for- 
mer lithiasis,  with  acute  obstruction  of  the  ductus 
choledochus).  The  post-operative  course  was  de- 
void of  complications,  and  the  operations  were  ab- 
solutely painless,  even  in  the  second  case,  ren- 
dered difficult  by  multiple,  long-standing  adhesions. 
Since  then  all  of  our  hepatic  and  biliary  opera- 
tions have  been  conducted  under  paravertebral 
anesthesia. 

Right-sided  paravertebral  infiltration  of  the  six 
lower  intercostals  and  first  two  lumbar  are  re- 
quired for  the  purpose.  Here,  as  in  the  case  of 
the  kidney  and  other  similar  operations,  one  is 
struck  by  the  frequent  diminution  of  post-opera- 
tive pain  in  the  succeeding  twenty-four  hours. 
The  method  allows  of  the  performance  of  chole- 
cystectomy. Vertical  or  transverse  incisions  may 
be  employed  provided  they  do  not  cross  the  median 
line.  The  cushion  placed  under  the  chest  may  be 
a  cause  of  suffering,  which  is  obviated  by  a  pre- 
vious injection  of  morphine. 


CHAPTER   VI. 

ANESTHESIA    OF    THE    GENITO-URINARY 
ORGANS   AND    RECTUM. 

The  pelvic  organs  and  external  genitalia  are 
supplied  by  the  internal  pudic  nerve,  the  small 
sciatic,  and  the  sacral  and  coccygeal  plexuses,  which 
anastomose  with  branches  from  the  pelvic  sympa- 
thetic. 


Fig.  147. — Nerve  supply  of  the  perineum  in  the  male. 
(Pauchet.)  '  Trunk  of  the  internal  pudic  nerve  and  branches 
of  the  small  sciatic. 


The    internal    pudic    nerve    emerges    from    the 

pelvis  through  the  great  sciatic  notch,  winds  around 

the  external  surface  of  the   sciatic  spine,   traverses 

the   ischio-rectal   fossa,    and   gives   filaments   to   the 

(200) 


GENITO-URINARY   ORGANS   AND   RECTUM.         201 


Fig.  148. — Nerve  supply  of  the  perineum  in  the  female. 
(Pauchet.)  Internal  pudic  nerve  and  branches  of  the  small 
sciatic. 


Fig.  149. — Sensory  segments  of  the  perineum  correspond- 
ing to  the  last  spinal  pair.  (Pauchet.)  The  branches  5"  indi- 
cate the  sacral  nerves,  with  the  number  of  the  foramen  of 
emergence.  The  branches  L  are  lumbar.  The  number  is  that 
of  the  corresponding  segment.     (See  also  Figs.  220  and  221.) 


202 


REGIONAL   ANESTHESIA. 


skin  of  the  perineum,  anus,  posterior  half  of  the 
scrotum,  penis,  and  vulva.  The  anterior  half  of 
the  scrotum  and  of  the  labia  majora  is  supplied 
by    the    genito-crural    and    the    ilio-inguinal.      The 


Fig.  ISO. — Pre-sacral  anesthesia.  (Pauchet.)  To  reach  all 
sacral  foramina  but  the  first,  the  needle  is  introduced  between 
the  anus  and  coccyx  and  follows  the  anterior  surface  of  the 
sacrum  to  each  foramen.  To  reach  the  first  sacral  foramen, 
the  needle  is  inserted  at  the  same  point  but  is  pushed  directly 
through  the  tissues  to  reach  the  sacral  brim  When  the  bone 
has  been  reached,  the  injection  is  made. 


2d,  3d  and  4th  sacral  pairs  constitute  the  hypo- 
gastric plexus,  and  through  it  supply  the  bladder, 
prostate,  uterus,  rectum,  and  pelvic  peritoneum. 

Regional  anesthesia  for  the  above  operations  is 
simple  and  easy  of  application,  and  the  various 
regions    involved    and    methods    of    treatment    are 


GENITO-URINARY   ORGANS    AND    RECTUM. 


203 


Fig.  151. — Trans-sacral  anesthesia.  (Pauchet.)  Note  the 
depth  to  which  the  needle  B  penetrates  to  reach  the  pos- 
terior foramen  Si.  On  the  contrary  B  finds  the  orifice 
S5  immediately  beneath  the  skin.  The  needle  penetrates  ap- 
proximately 25  millimeters  to  reach  the  first  sacral  foramen, 
20  for  the  second,  15  for  the  third,  and  10  for  the  fourth,  and 
should  be  driven  about  1  centimeter  into  each  canal  in  order 
to  reach  the  anterior  as  well  as  the  posterior  division  of  the 
nerve.  It  is  well  to  introduce  the  index  finger  into  the  rectum 
in  order  to  be  certain  that  the  point  of  the  needle  is  not  pene- 
trating the  rectal  wall. 


204 


REGIONAL   ANESTHESIA. 


Fig.  152. — Pre-sacral  and  trans-sacral  anesthesia.  (Pauchet.) 
The  first  of  these  procedures  is  indicated  in  the  obese  and  the 
second  in  thin  subjects.  In  the  latter  the  bony  landmarks  are 
more  easily  found.  Note  the  direction  followed  by  the  pre- 
sacral needle  for  each  foramen.  The  first  four  anterior  arrows 
reach  the  foramina  5,  4,  3,  and  2.  The  needle  point  should  be 
kept  in  constant  contact  with  the  concavity  of  the  sacrum,  and 
should  always  be  parallel  to  the  middle  line  of  this  bone.  The 
arrow  destined  for  Si  aims  directly  at  the  superior  strait  of 
the  pelvis.  As  soon  as  it  comes  in  contact  with  this,  the  needle 
is  at  the  sacral  foramen  Si.  If  injury  of  the  rectum  is  appre- 
hended, a  finger  should  be  inserted  in  it  during  the  introduc- 
tion of  the  needle. 


GENITO-URINARY   ORGANS    AND    RECTUM.         205 

fully  shown  in  Figs.  147  to  158.  In  Fig.  152  are 
shown  the  two  methods  of  application.  In  thin 
subjects  the  injections  are  made  through  the  five 
sacral  foramina.  In  stout  subjects  it  is  often 
easier  to  reach  the  sacral  nerves  by  introducing 
the  needle  at  a  point  between  the  rectum  and  the 
tip  of  the  coccyx,  and  infiltrating  the  concavity  of 
the  sacrum  with  a  i  per  cent,  solution  of  pro- 
caine-adrenin. 

Anterior  Sacral   (Pre-sacral)   Anesthesia. 

The  patient  is  placed  in  the  dorsal  position, 
with  the  thighs  flexed  upon  the  abdomen.  After 
proper  preparation  of  the  skin  with  iodine  and 
alcohol,  an  intra-dermal  wheal  is  formed  at  a 
point  midway  between  the  anus  and  the  tip  of  the 
coccyx,  thus  permitting  the  introduction  of  the  suc- 
cessive  needles   without   pain. 

Through  the  wheal  thus  formed  a  needle  9 
centimeters  long  is  introduced  and  with  its  point 
the  inferior  and  outer  border  of  the  sacrum  about 
2  centimeters  from  the  median  line  is  found.  The 
needle  is  now  pushed  forward,  with  its  point  in 
constant  contact  with  the  anterior  face  of  the 
sacrum,  for  about  i  centimeter,  which  should 
bring  the  point  to  a  level  with  the  fifth  sacral 
foramen.  Five  mils  of  a  i  per  cent,  solution  are 
thereupon   injected. 

One  then  continues  upward,  parallel  and  at 
about  2  centimeters  from  the  median  line,  keeping 
the  needle  point  constantly  in  contact  with  the  sur- 


206  REGIONAL   ANESTHESIA. 

face  of  the  bone,  at  a  distance  of  about  i^  to 
2  centimeters  from  the  point  already  injected, 
when  it  should  be  at  the  level  of  the  fourth  sac- 
ral foramen.  Here  again  5  mils  of  i  per  cent, 
solution  are  injected.  Then,  with  the  needle  in 
contact  with  the  bone  and  always  about  2  centi- 
meters from  the  median  line,  one  proceeds  about 
1^2  to  2  centimeters  higher  up  to  the  third  fora- 
men, where  5  mils  should  again  be  injected.  In 
the  same  manner  the  needle  is  pushed  upward  a 
fourth  time  to  the  second  foramen,  where  the 
same  amount  of  solution  is  again  injected.  The 
needle  is  next  drawn  back  to  the  starting  point 
and  the  same  manipulation  repeated  on  the  oppo- 
site side  of  the  median  line,  thus  bringing  under 
control  both   sets  of  nerves. 

The  first  needle  is  now  replaced  by  one  12 
centimeters  long,  the  gloved  finger  placed  in  the 
rectum,  and  the  needle  introduced  at  the  same 
point.  Instead  of  following  the  surface  of  the 
bone,  however,  one  next  pierces  directly  upward 
to  a  depth  of  9  to  10  centimeters,  and  with  the 
finger  in  the  rectum  aiding  as  a  guide,  aims  to 
strike  the  upper  part  of  the  sacrum  as  it  tilts 
forward.  At  this  depth,  about  2^/^  centimeters 
from  the  median  line  and  against  the  bone,  the 
first  sacral  foramen  is  attained.  Five  mils  of  solu- 
tion are  injected  and  the  procedure  repeated  on 
the  opposite  side.  The  last  injection  is  an  extra 
precaution.  As  a  rule  it  is  not  needed,  complete 
anesthesia  of  the  parts  being  secured  by  injection 
of  the  other  four  pairs. 


GENITO-URINARY   ORGANS    AND    RECTUM. 


207 


Anesthesia  Through  the  Sacral  Foramina — 
Trans-sacral  Anesthesia. 

The   patient   is   placed   in   the   extended   posture 
and   face   down  upon   the   table.      With   the   aid   of 


Fig.  153. — Location  of  the  posterior  sacral  foramina. 
(Paucliet.)  MM',  middle  line  of  the  body.  V,  spinous  proc- 
ess of  the  5th  Imnbar  vertebra.  /-/'  lines  joining  the  iliac 
crests.  TT',  postero-inferior  spines  of  the  ilia.  H,  fourth 
sacral  spinous  process.    CC,  sacral  cornua.    X,  sacral  hiatus. 

a  dermographic  pencil,  a  line  is  drawn  from  the 
crest  of  one  ilium  to  that  of  the  other  (Fig. 
156,  CC).  The  relationship  of  the  posterior  supe- 
rior spines  of  the  ilia  is  shown  at  EE.  The 
sacral  cornua,  BB,  are  now  found  and  marked. 
From  top  to  bottom  a  line  is  drawn  directly  over 


208 


REGIONAL   ANESTHESIA. 


the  median  line  from  D  to  A.  A  point  4  centi- 
meters on  each  side  from  the  median  hne,  on  the 
line    CC,    is   marked.      This    point    is    connected   on 


Fig.  154. — Posterior  surface  of  the  sacrum,  showing  the 
posterior  sacral  foramina  and  sacral  nerves.  (Pauchet.)  A, 
the  interiliac  line.  B,  line  joining  the  two  postero-inferior 
iliac  spines.  M,  line  joining  the  two  middle  spinous  processes. 
C,  horizontal  line  passing  through  the  two  sacral  cornua  at 
the  level  of  the  sacral  foramen,  S5.  The  oblique  line  corres- 
ponds to  the  situation  of  the  sacral  foramina;  it  is  located 
25  millimeters  from  the  middle  line  at  the  level  of  the  two  sac- 
ral cornua.  Note  that  the  lumbo-sacral  space,  through  which 
spinal  anesthesia  may  be  induced  (Le  Filliatre)  is  at  the  mid- 
dle of  the  interval  that  separates  A  from  B.  K,  point  cor- 
responding to  the  fourth  sacral  spinous  process.  S4  is  situated 
1  centimeter  outside  of  K. 


each  side  by  a  hne  drawn  downward  to  the 
point  B.  The  hne  passes  directl}^  over  the  five 
sacral  foramina.  Commencing  at  the  top,  the  first 
foramen  is  found  on  this  line  directly  opposite  the 


GENITO-URINARY   ORGANS    AND    RECTUM  209 

tip  of  the  spinous  process  of  the  fifth  lumbar 
vertebra    (Fig.    153). 

At  a  point  3^  centimeters  below  on  the  same 
line  will  be  found  the  second  foramen.  Two  and 
one-half  centimeters  further  down  is  the  third;  2 
centimeters  down  is  the  fourth,  and  i^  below 
this  is  the  fifth.  The  first  is  about  35  mm.  from 
the  median  line ;  the  second,  30 ;  the  third,  25 ;  the 
fourth,  20,   and  the  fifth,    15   mm. 

Technique  of  the  Injections. — The  spine  is 
painted  with  iodine,  which  is  then  removed  with 
alcohol.  With  a  fine  needle  five  dermal  wheals 
are  injected  on  each  side  of  the  median  line  at 
points  overlying  the  sacral  foramina.  One  com- 
mences at  the  top  w'ith  a  needle  9  centimeters 
long;  if  it  does  not  at  once  enter  the  foramen  the 
operator  will  readily  find  the  opening  b}^  feeling 
about  with  the  point  of  the  needle.  The  latter 
should  penetrate  to  a  depth  of  about  25  mm.  for 
the  first  foramen;  20  mm.  for  the  second;  15  mm. 
for  the  third;  10  for  the  fourth,  and  5  for  the 
fifth.  Five  mils  of  a  i  per  cent,  solution  are  to 
be   injected   at   each   opening. 

In  feeling  about  with  the  point  of  the  needle, 
seeking  the  opening,  the  operator  will  suddenly 
sense  the  absence  of  resistance  as  the  needle  en- 
ters the  foramen,  and  at  the  same  moment  the 
patient  is  likely  to  complain  of  a  disagreeable  sen- 
sation in  the  abdomen  or  legs  which  is  proof  that 
the  nerve  has  been  struck.  After  fifteen  minutes 
the  operation  can  be  begun.  The  anesthesia  lasts 
from   one  and   one-half   to   two   hours. 

14 


210 


REGIONAL   ANESTHESIA. 


Fig.  155. — T-rans-sacral  anesthesia  of  the  pelvic  organs  and  pelvic 
peritoneum.  The  two  iliac  crests  should  be  felt  for  and  the  line  AB 
marked  out.  The  prominent  postero-inferior  spine  is  at  C,  and  the 
sacral  cornu  at  D  (sacro-coccygeal  articulation).  C  is  placed  slightly 
too  high  in  the  sketch.  The  reader  will  notice  at  his  right  the  promi- 
nent postero-inferior  spine  exactly  outside  of  the  sacral  foramen,  S2. 
S§  is  exactly  outside  of  the  sacral  cornu.  S2  and  Si  are  separated  by 
the  width  of  the  thumb,  as  are  also  S2  and  S3.  S4  and  S5  are  sep- 
arated by  the  width  of  the  little  finger;  the  former  corresponds  to  the 
summit  of  the  sacral  hiatus.  The  sacral  foramina  are  situated  on  a 
line  starting  from  the  sacral  cornu  15  millimeters  from  the  median 
line  and  ending  at  the  line  AB,  35  millimeters  from  the  median  line. 
Z,  the  lumbosacral  hiatus,  is  at  the  same  distance  from  S2  and  from 
AB.  XY  corresponds  to  the  5th  lumbar.  These  landmarks  are  utilized 
in  posterior  sacral  anesthesia  as  well  as  in  spinal  anesthesia. 


GENITO-URINARY    ORGANS    AND    RECTUM. 


211 


Sacral  injections  anesthetize  the  labia,  pros- 
tate, bladder,  rectum,  anus,  uterus,  and  skin  of 
the  posterior  surface  of  the  thigh.  We  use  this 
method    to    do    prostatectomies,    extirpation    of    the 


C  .EJ^f  j)^j-^.  C 


Fig.  156. — Trans-sacral  anesthesia.  (Pauchet.)  (Posterior  land- 
marks: Fig.  155).  CC,  inter-iliac  line.  EB,  BE,  a  trapezoid  figure 
the  base  of  which  measures  8  centimeters  and  the  summit,  3  centi- 
meters. The  points  BB  correspond  to  the  sacrococcygeal  articulation 
and  the  cornua  of  the  sacrum;  they  are  located  15  millimeters  from 
the  midline.  The  5th  sacral  foramen  is  situated  immediately  outside 
of  them.  Ei,  postero-inferior  iliac  spine  (here  shown  a  little  high). 
The  black  dot  between  D  and  the  line  Ei,  Ei  should  be  at  equal  dis- 
tance from  D  and  Ei,  Ei,  i.e.,  in  the  lumbo-sacral  space  or  area  of 
election  for  lumbar  puncture.  The  distance  separating  each  sacral 
foramen  from  the  midline  is  also  shown.  The  finger,  T,  shows  that 
there  is  a  finger-breadth  of  distance  between  the  sacral  foramina.  The 
needle  is  entering  foramen  No.  4. 


212 


REGIONAL   ANESTHESIA. 


rectum,  radical  cure  of  prolapsus  uteri,  all  vesical 
operations,  curettage  of  the  uterus,  and  catheter- 
ization of  the  ureters  in  man  (for  tuberculosis, 
cystitis,  etc.),  but  the  parietal  peritoneum  is  not 
sufficiently  anesthetized  to  permit  of  a  hysterectomy. 
(See  also   Figs.   220  and  221,   p.   282.) 


Fig.  157. — Trans-sacral  anesthesia  in  man.  (Pauchet.) 
This  permits  of  operating  upon  a  cancer  of  the  rectum,  hemor- 
rhoids, prostatic  adenoma,  tumor  of  the  bladder,  amputation  of 
the  penis,  etc. 

Operations  upon  the  Bladder, 
suprapubic  cystostomy. 
To  perform  a  suprapubic  cystostomy,  the  trans- 
sacral   and    hypogastric    forms    of    anesthesia    com- 
bined are  necessary.     For   a   cystostomy  a  lozenge 


GENITO-URINARY    ORGANS    AND    RECTUM. 


213 


is  made  the  long  axis  of  which  corresponds  to  the 
lower  half  of  the  distance  between  the  umbilicus 
and  the  pubis.  The  skin  and  muscles  are  infil- 
trated with  the  weak  solution.  The  bladder  is 
not  anesthetized;  but  infiltration  of  the  space  of 
Retzius   sufficiently   diminishes    its    sensibility.      One 


Fig.  158. — Trans-sacral  anesthesia  in  woman.  (Pauchet.) 
The  gray  area  shows  the  region  anesthetized  by  injection  of 
the  sacral  nerves  (pelvis  and  perineum).  This  enables  the 
surgeon  to  operate  upon  cancer  of  the  rectum,  hemorrhoids, 
prolapsus  uteri,  or  cystocele,  and  the  obstetrician  to  use  for- 
ceps without  pain. 


should  add  an  intravesical  injection  of  50  mils  of 
a  ^  per  cent,  solution,  allowed  to  remain  during- 
fifteen  or  twenty  minutes  for  a  simple  section  and 
vesical    exploration.      The   bladder    is    rendered    en- 


214 


REGIONAL   ANESTHESIA. 


tirely  insensitive  by  the  sacral  injections,  but  the 
abdominal  wall  must  be  infiltrated  in  addition  be- 
fore  it   is   incised. 


Fig.  159. — Suprapubic  cystostomy.  (Pauchet.)  The  opera- 
tor makes  two  wheals,  1  and  2;  then  infiltrates  the  subcuta- 
neous cellular  tissues  for  a  thumb's  width  to  the  right  and  left, 
and  the  two  recti  abdominis.  Through  wheai  1,  he  injects  the 
space  of  Retzius  in  order  to  desensitize  the  bladder. 


Operations  upon   the  Testicles  and 
Scrotum. 

The  operator  should  first  anesthetize  the  cord, 
then  make  a  ring  of  anesthesia  about  the  base  of 
the  scrotum,  on  both  sides.  A  wheal  is  made 
over  the  external  abdominal  ring".  With  the  left 
hand,  the  cord  is  held  firmly  over  the  pubis,  a 
needle  detached  from  the  syringe  inserted,  the  cord 


GENITO-URINARY   ORGANS   AND   RECTUM. 


215 


Fig.  160. — Anesthesia  of  the  testicle.  (Pauchet.)  Infiltra- 
tion of  the  cord  by  transfixion  of  it  upon  the  pubis.  In  order 
not  to  miss  the  cord,  the  needle  is  pushed  successively  in  two 
or    three    divergent    directions. 


Fig.  161. — Anesthesia  of  the  testicle.  (Pauchet.)  Infiltra- 
tion of  the  cord.  The  latter  is  pinched  between  the  fingers 
through    the    skin,    raised    between   two   fingers,    and    injected. 


216 


REGIONAL   ANESTHESIA. 


transfixed  upon  the  pubis,  then,  after  shght  with- 
drawal of  the  needle,  5  mils  of  the  weak  solu- 
tion injected;  this  infiltrates  the  cord.  To  make 
certain,  the  maneuver  is  repeated  and  the  cord 
immobilized  upon  the  pubis,  transfixed,  and  infil- 
trated  with    5    mils    of    the    weak    solution.      Then, 


Vx 


Fig.  162. — Operations  upon  the  scrotum.     (Pauchet.)     A  band 
of  subcutaneous  infiltration  circumscribes  its  base. 


with  the  left  index  finger,  the  operator  finds  the  exter- 
nal inguinal  ring,  introduces  the  needle  from  6  to 
9  centimeters  into  the  inguinal  canal,  and  injects 
anew   10  mils  of  the  weak  solution. 

To  anesthetize  the  scrotum,  the  operator  should 
work  all  the  way  round  its  base,  starting  at  the 
lower   surface   of   the   penis,   and,   passing   around. 


GENITO-URINARY   ORGANS    AND    RECTUM.         217 

infiltrate  the  subcutaneous  tissue  until  he  gets 
back  to  the  starting  point.  He  then  passes  in 
front  of  the  perineum  and  in  the  genito-crural 
folds.  The  weak  solution  is  sufficient;  50  mils, 
more  or  less,   are  required. 

Operations  upon  the  Penis. 

If  it  is  desired  to  effect  merely  a  dorsal  incision 
of  the  prepuce,  with  simple  section  of  the  frenum. 


Fig.  163. — Anesthesia  of  the  prepuce  by  a  coronal 
injection.     (Pauchet.) 

the  skin  should  be  infiltrated  in  the  median  line 
by  the  "Reclus  method"  from  the  anterior  aspect  of 
the  prepuce  to  the  corona  of  the  glans.  One  is 
thus  enabled  to  slit  the  prepuce  with  scissors  and 
suture  the  borders  of  the  wound.  A  second  in- 
jection being  made  at  the  level  of  the  frenum, 
this    may   be    split    and    one   or    two    sutures    taken 


218 


REGIONAL   ANESTHESIA. 


in  it.     We  favor  this  simple  operation,  rather  than 
that  of  circumcision. 

If  the  operator  wishes  to  do  an  ordinary  cir- 
cumcision, amputate  the  penis,  or  operate  upon  a 
hypospadias,  it  will  be  necessary  for  him  to  insti- 
tute a  total  anesthesia  of  the  penis  in  the  follow- 
ing manner:  A  wheal  is  made  at  the  right  and 
left    of    the    root    of    the    penis,    where    the    cord 


Fig.  164. — Anesthesia  of  the  penis.  (Pauchet.)  Through 
two  wheals  an  injection  is  made  at  first  deeply  up  to  the  roots 
of  the  corpora  cavernosa  and  the  suspensory  ligament,  then 
under  the  skin  in  circular  fashion. 


crosses  over  the  horizontal  ramus  of  the  pubis. 
Through  this  wheal  the  needle  is  introduced  up  to 
the  corpora  cavernosa,  under  the  suspensory  liga- 
ment of  the  penis,  and  deeply  around  the  penis. 
Forty  mils  of  a  ^  per  cent,  solution  of  procaine- 
adrenin    are    injected.      This    injection    will    anes- 


thetize    the 
penis,   etc. 


urethra,     corpora     cavernosa,     glans 


genito-urinary  organs  and  rectum.       219 

Operations  upon  the  Posterior  Urethra. 

For  suture  of  the  urethra,  urethrotomy,  etc., 
a  wheal  is  first  made  in  front  of  the  anus  in  the 
median  Hne.  Then,  through  this  wheal,  the  ver- 
tical plane  of  tissue  that  separates  the  anus  and 
rectum  behind  from  the  urethra,  bulb,  and  pros- 
tate in  front  is  infiltrated.  The  left  index  finger 
is  placed  in  the  rectum  and  with  the  right  hand 
a  9-centimeter  needle  is  taken  and  passed  in  in 
the  median  line,  very  high  up  between  the  pros- 
tate and  rectum;  the  operator  now  injects  while 
withdrawing  it.  He  then  begins  anew,  without 
wholly  withdrawing  the  needle,  and  passes  to  the 
right  and  to  the  left,  in  order  to  infiltrate  a  space 
9  centimeters  high  and  2  or  3  wide.  This  plane 
separates  the  rectum  and  anus  behind  from  the 
prostate  and  urethra  in  front.  All  the  subcutane- 
ous cellular  tissues  and  the  muscles  should  be  in- 
filtrated. 

Finally,  it  is  necessary  to  infiltrate  the  plane 
of  section  corresponding  to  the  incision  in  peri- 
neotomy for  operations  on  the  prostate.  The  op- 
erator may  in  this  way  go  up  as  high  as  the 
neck  of  the  bladder  and  the  prostate  with  per- 
fect anesthesia.  Yet,  anesthesia  by  the  sacral  fora- 
mina is  in  every  way  preferable. 


220  regional  anesthesia. 

Operations  upon  the  Prostate, 
prostatectomy. 

A  choice  may  be  made  from  one  of  the  four 
following  methods  of  anesthesia : 

1.  Periprostatic  infiltration  through  the  bladder. 

2.  Periprostatic  infiltration  through  the  peri- 
neum. 

3.  Anterior    sacral   anesthesia. 

4.  Posterior    trans-sacral    anesthesia. 

I.  Periprostatic  Anesthesia  Through  the  Blad- 
der.— (a)  The  operator  begins  by  anesthetizing 
the  abdominal  wall,  as  for  a  cystotomy,  then  the 
space  of  Retzius.  The  simple  infiltration  of  these 
tissues  yields  a  satisfactory  anesthesia.  The  injec- 
tion must  be  carefully  pushed  into  the  entire 
thicknesses  of  the  muscles,  in  order  to  be  able  to 
separate  them   without  pain. 

{h)  For  anesthesia  of  the  prostate,  the  blad- 
der having  been  opened,  the  operator  takes  a  long 
curved  needle  (Legueu's)  and  passes  through  the 
mucosa  of  the  bladder  around  the  prostate,  with 
the  finger  as  guide.  Approximately  150  mils  of 
the  weak  solution  of  procaine-adrenin  is  used. 
Five  or  six  minutes  after  this  infiltration  the  op- 
erator may  begin  removing  the  prostate. 

2.  Periprostatic  Anesthesia  Through  the  Peri- 
neum.— The  operator,  after  having  infiltrated  the 
abdominal  wall  as  in  the  preceding  method  for  a 
suprapubic  section,  must  anesthetize  the  tissues 
between  the  two  ischia,  comprising  the  skin  and 
soft   parts    situated   between   the   urethra   in   front, 


GENITO-URINARY   ORGANS    AND   RECTUM. 


221 


and  the  rectum  and  anus  behind.  This  form  of 
infihration  is  useful  for  all  operations  upon  the 
perineum    (see   Fig.    165). 

To  reach  the  prostate,  the  operator  places  his 
left  index  finger  in  the  rectum  in  contact  with  the  hy- 
pertrophied  organ.  With  the  right  hand  a  9- 
centimeter  needle  is  introduced  into  the  perineum 
and  guided  up  toward  the  prostate   by  the   aid  of 


Fig.  165. — Anesthesia  of  the  anterior  portion  of  the  perineum 
through  a  wheal  in  front  of  the  anus.     {Pauchet.) 


a  finger  in  the  rectum.  When  the  needle  has  at- 
tained the  periprostatic  region,  50,  60,  or  80  mils 
of  the  weak  solution  of  procaine-adrenin  are 
injected. 

3.  Anterior  Sacral  Method. — This  consists  in 
infiltrating  all  of  the  concavity  of  the  sacrum  with 
a  I  per  cent,  solution.  The  needle  should  pass 
between   the   rectum   in   front   and   the   sacrum   be- 


222  REGIONAL   ANESTHESIA. 

hind.  The  operator  injects  approximately  5  mils 
of  procaine-adrenin  opposite  each  one  of  the  sacral 
foramina.  It  is  unnecessary  to  inject  the  upper 
foramen  (see  Fig.  152  and  detailed  descriptions, 
including  that  of  the  trans-sacral  method,  at  the 
beginning  of  this  chapter). 

4.  Trans-sacral  Method. — The  operator  must 
be  experienced  before  such  an  anesthesia  will 
prove  perfectly  satisfactory,  but  after  some  ex- 
perience the  trans-sacral  method,  which  is  by  long 
odds  the  best,  will  be  the  one  chosen. 

With  this  procedure,  very  little  of  the  anes- 
thetic is  required,  and  all  that  is  needed  in  addi- 
tion is  the  injection  of  the  anterior  abdominal 
wall. 

Operations  upon  the  Vulva  and  Vagina. 

The  posterior  half  of  the  vulva  is  supplied  by 
the  sacral  nerves;  the  anterior  half,  by  the  ilio- 
inguinal and  genito-crurals.  If  the  operation  in- 
dicated is  one  of  minor  importance,  it  is  best  to 
anesthetize  the  vulva  directly.  Three  wheals  are 
made,  a  middle  one  in  front  of  the  anus,  and  2 
lateral  ones  at  the  lower  terminations  of  the  labia 
majora.  The  soft  tissues  outside  the  labia  majora 
are  then  infiltrated,  thus  completing  the  anesthe- 
sia   (Fig.    166). 

Where  it  is  desired  to  anesthetize  the  vesti- 
bule of  the  vagina,  the  above  method  is  not  suffi- 
cient. One  must  infiltrate  with  the  weak  solution, 
following  a  frontal  plane,  in  the  manner  already 
described  for  a  perineotomy  in  the  male.     To  infil- 


GENITO-URINARY   ORGANS   AND    RECTUM. 


223 


trate  the  recto-vaginal  septum,  a  finger  should  be 
introduced  in  the  vulva  or  rectum  to  guide  the  9- 
centimeter  needle.  One  then  infiltrates  after  Rec~ 
lus's  method,  using  100  mils  of  the  solution.  After 
this  one  may  operate  for  a  recto-vaginal  fistula, 
perform   a   perineorrhaphy,    etc. 


Fig.  166. — Anesthesia  of  the  vulva  and  vestibule.     (Pauchet.) 


LIBERATION   OF  THE  VAGINA  AND  OF  THE  UTERUS 
PROLAPSE,    COLPORRHAPHY,    COLPOTOMY. 

The  preceding  methods  may  be  sufficient;  this 
simple  infiltration,  however,  does  not  anesthetize 
the  pelvic  f^oor.  The  vaginal  vault  should  be  in- 
filtrated in  addition.  To  do  this,  the  cervix  of  the 
uterus  is  brought  down  until  it  shows  at  the  vulva; 


224  REGIONAL   ANESTHESIA. 

a  9-centimeter  needle  is  introduced  into  the  an- 
terior cul-de-sac,  and  20  mils  of  solution  injected 
between  the  bladder  and  the  cervix  (not  under 
the  mucotis  membrane).  Another  injection  is  now 
made  under  the  urethral  meatus,  and  this  time 
right  and  left  injections  made  on  each  side  under 
the  mucous  membrane;  10  mils  of  solution  are 
used.  The  cervix  is  pulled  to  the  right  and  an 
injection  made  into  the  left  lateral  cul-de-sac,  in- 
filtrating the  base  of  the  broad  ligament,  using 
15  mils.  The  operator  begins  anew  on  the  right 
side,  then  introduces  the  9-centimeter  needle  into 
the  posterior  cul-de-sac,  between  the  vaginal  mu- 
cous membrane  and  Douglas's  cul-de-sac,  injecting 
20  mils.  The  uterus  is  now  released  and  the 
perineum  infiltrated  as  previously  described.  In  all 
at  least  200  mils   are  necessar}'-. 

A  satisfactory  anesthesia  is  obtained  in  a  pre- 
cise and  simple  way  wnth  the  sacral  method;  but 
by  this  procedure  no  hemostasis  is  assured,  while 
on  the  contrary,  if  infiltration  is  practised  after 
Reclus's  method,  the  operation  is  bloodless.  In 
perineorrhaphy  this  is  an  advantage;  from  the 
anatomical  point  of  view,  however,  the  sacral 
method  is  more  attractive,  and  we  give  it  preference. 

Operations  upon  the  Anus. 

The  trans-sacral  procedure  is  very  satisfactory 
in  operations  upon  the  anus.  The  perineal  infil- 
tration gives  not  only  a  good  anesthesia,  but  also 
a   perfect   ischemia.      All   will   agree   that   to   extir- 


GENITO-URINARY   ORGANS    AND    RECTUM 


22; 


pate  hemorrhoids  without  the  loss  of  a  drop  of 
blood  is  ideal.  For  this  reason,  we  give  pref- 
erence to  the  Whitehead  operation,  and  infiltrate 
at  a  distance  around  the  anus  and  rectum  when 
the  operation  is  practised,  as  upon  a  cadaver. 

Four    dermal    wheals    are    made    in    a    lozenge 
form,  one   in  front  of  the  anus,  two  laterally,   and 


Fig.  167. — Anesthesia  of  the  anal  region  through  four 
wheals  circumscribing  the  anus  and  at  some  distance  from  it. 
{Pauchet.) 


the  last  behind,  not  too  close,  two  finger-breadths 
from  the  anal  orifice  (Fig.  167  and  169).  Through 
these  four  points  all  the  injections,  using  3^  per 
cent,  solution,  are  made.  Through  the  perineal 
wheal,  the  needle  is  introduced,  at  first  perpen- 
dicularly to  the  surface,  and  afterward  in  a  fan- 
shaped   manner,    right    and   left,    each  time   4  or    5 

15 


226 


REGIONAL   ANESTHESIA. 


mils  of  the  solution  being  injected  deeply  in  the 
sphincter  and  under  the  skin.  Through  the  lateral 
wheals  fan-shaped  injections  are  also  made,  paral- 
lel to  the  rectal  walls,  reaching  the  levator  ani, 
and  bathing  the  ischio-rectal  fossae,  the  sphincter, 
and  the  subcutaneous  and  submucous  tissues   (Fig. 


Fig.  168. — Radiating  injections  through  the  lateral  wheal. 
(Pauchet.)  The  figure  shows  the  three  positions  in  which  the 
needle  should  be  placed  in  order  to  infiltrate  the  entire  mass  of 
tissue  with  quinine  through  a  single  wheal. 


i68).  Finally,  a  mass  oi'  tissue  is  also  infiltrated 
behind  the  anus  and  rectum,  in  fan-shaped  fashion. 
The  rectum  is  completely  surrounded  by  the  in- 
filtration. 


GENITO-URINARY   ORGANS    AND    RECTUM. 


227 


>D 


Fig.  169. — Radical  cure  of  hemorrhoids  by  Whitehead's  op- 
eration. (Pauchet.)  Through  wheals  A,  B,  C  and  D,  a  band 
of  tissue  is  infiltrated  along  the  dotted  lines.  Through  the 
same  wheal  deep  radiating  injections  are  then  made  in  the 
sphincter  and  adipose  tissue  of  the  ischio-rectal  fossa,  com- 
pletely surrounding  the  ano-rectal  cylinder. 


'^iii-umMiii^ 


Fig.  170. — Peripheral  infiltration  with  quinine  for  incision 
of  fistula  in  ano.     {Pauchet.) 


228  REGIONAL   ANESTHESIA. 

At  the  close  of  the  infiltration,  when  the  latter 
has  been  successful,  the  sphincter  is  gaping.  In 
a    few    minutes,    dilatation,    dissection    and    descent 


Fig.  171. — Anorectal  segment  laid  open  after  extirpation. 
{Pauchet.)  Trans-sacral  anesthesia  is  employed.  The  cancer- 
ous tumor  forms  a  hollow  cylinder. 

of  the  mucosa,  resection,  and  cauterization  can  be 
effected  without  pain  and  without  hemorrhage  of 
any  account.  According  to  the  degree  of  stout- 
ness  of   the   patient,    50   or    100   mils   of   the   solu- 


GENITO-URINARY    ORGANS   AND    RECTUM.         229 

tion  are  required.  Beginners  should  place  a  fin- 
ger  in  the   rectum  to   guide   the  needle. 

Operations  for  fistula  in  ano  may  be  done 
under   the   same   method   of  infiltration. 

We  have  often  practised  total  extirpation  of 
the  rectum,  with  al^solute  anesthesia — always  by 
the  trans-sacral  method.  Infiltration  is  not  suffi- 
cient. We  practice  the  anterior  or  posterior 
method,  according  to  the  degree  of  stoutness  of 
the   patient. 


CHAPTER    VII. 

ANESTHESIA  OF  THE  EXTREMITIES. 

Reduction  of  Fractures  or  Dislocations — 
QuENu's   Method. 

In  1907,  Quenu  recommended  the  use  of  local 
anesthesia  for  the  reduction  of  fractures  and  dis- 
locations. 

The  procedure  consists  in  injecting  in  the 
vicinity  of  the  fracture  an  anesthetic  solution  so 
that  the  hone  ends  are  bathed  with  it,  the  seat 
of  the  fracture  being  thus  rendered  insensitive. 
The  muscles  simultaneously  relax,  and  one  may 
proceed  without  pain  to  dress  the  wound,  exam- 
ine the  parts,  reduce,  practice  radioscopy,  etc. 
For  dislocations,  the  injection  is  made  into  the 
synovial  sac,  then  about  the  dislocated  articula- 
tion and  the  insertion  of  the  muscles  surrounding 
it.  The  previously  rigid  limbs  become  supple  and 
mobile,  muscular  contractions  cease,  and  reduc- 
tion becomes  easy  and  painless.  A  i  per  cent, 
or  Yz  per  cent  procaine-adrenin  solution  is  in- 
jected,  according  to  the   stoutness  of  the  patient. 

It  will  not  be  necessary  to  describe  the  pro- 
cedure for  every  type  of  fracture  or  dislocation,  the 
technique  of  the  injection  being  practically  the 
same  in  all.  The  procedure  is  easy  and  devoid 
of  risk  if  a  fine  needle  is  used.  A  point  at 
which  the  skin  is  not  distended,  contused,  or  trau- 
(230) 


ANESTHESIA  OF  THE  EXTREMITIES. 


231 


matized  in  any  way  should  be  selected.     In  juxta- 
articular     fractures,     the     fracture     and    the     joint 


Fig.  172. — Anesthesia  for  reduction  of  an  elbow  dislocation. 
(Pauchet.)  The  quinine-urea  solution  is  injected  in  the  syn- 
ovial sac  of  the  articulation  and  infiltrates  the  insertions  of  the 
muscles  about  the  joint. 


should    be    simultaneously    injected.  In    the    lower 

extremities  this  is  the  procedure  of  choice.     In  the 

upper,    one    may,    with    experience,  instead,    anes- 
thetize  the  brachial   plexus. 


232  REGIONAL   ANESTHESIA. 

Upper  Extremity. 
The  upper  extremity  as  a  whole,  below  the 
shoulder,  receives  its  sensory  supply  from  the 
brachial  plexus,  whi-ch  becomes  united  beyond  the 
scaleni  into  a  single,  comparatively  narrow,  cord. 
The  upper   intercostal  nerves   contribute   in   supply- 


Fig.  173. — Anesthesia  for  fracture  of  the  humerus.  (Pau- 
chet.)  The  needle  is  introduced  at  the  site  of  fracture  and 
quinine-urea  solution  injected  throughout  the  region. 

ing  the  axilla  with  sensation  and  also  furnish  a 
portion  of  the  sensibility  of  the  skin  of  the  inner 
surface  of  the  arm.  The  skin  of  the  shoulder 
region  is  supplied  by  filaments  from  the  supra- 
clavicular   branches    of    the    cervical    plexus. 


ANESTHESIA  OF  THE  EXTREMITIES.  233 


ANESTHESIA    OF    TEIE    BRACHIAL     PLEXUS     BY     WAY 
OF    THE    AXILLA HIRSCHEL. 

The  arm  is  extended  in  strong  abduction  (Fig. 
174).  With  the  left  hand  fixing  the  axillary 
artery,  the  needle  is  introduced  high  up  as  far  as 
possible  under  the  pectoralis  major,  following  the 
longitudinal  axis  of  the  arm.  The  injection  is  be- 
gun during  the  introduction  of  the  needle  in 
order  to  push  aside  and  avoid  wounding  the  blood- 


Fig.  174. — Infiltration  of  the  brachial  plexus  by  way  of  the 
axilla.  (Pauchet.)  Below  the  inferior  border  of  the  pec- 
toralis major,  with  the  arm  abducted,  the  needle  is  intro- 
duced toward  the  nervous  trunks,  in  a  direction  parallel  with 
the  axis  of  the  arm. 

vessels.  With  a  few  syringefuls  of  the  solution, 
the  median  nerve  is  blocked  above,  and  the  ulnar 
further  anteriorly.  To  reach  the  radial  nerve,  one 
must  penetrate  more  deeply  under  the  artery,  al- 
most to  the  height  of  the  insertion  of  the  pec- 
toralis major.  The  artery  is  there  surrounded 
with  injections,  and  with  proper  caution  injury  to 
it  or  to  the  vein  is  avoided.  Thirty  or  40  mils  of 
the  2   per  cent,   solution  are  used. 


234 


REGIONAL   ANESTHESIA. 


ANESTHESIA   OF   THE    BRACHIAL   PLEXUS    BY   THE 
SUPRACLAVICULAR     ROUTE KULENKAMPFF. 

The  location  of  the  plexus  is  well  shown,  with- 
in by  the  subclavian  artery,  the  pulsations  of 
which  can  easily  be  felt;  below,  by  the  first  rib, 
and  in  front,  by  the  clavicle.  Figure  175  shows 
the  direction  of  the  first  rib,  the  supraclavicular 
region   being    seen    in    profile.      It    ascends    behind 


Fig.  175. — Blocking  the  nerve  trunks  of  the  upper  extremity. 
(Pauchet.)  A,  scalenus  posticus.  B,.  apex  of  the  pleura.  C, 
omo-hyoid.  D,  point  where  the  wheal  should  be  made.  E, 
subclavian  artery.     F,  scalenus  anticus.     G,  sterno-mastoid. 

the  clavicle  and  at  a  right  angle,  and  is  an  im- 
portant landmark,  for  it  indicates  the  extreme 
point  of  penetration  of  the  needle.  The  dermal 
wheal  should  be  made  at  about  the  middle  of  the 
clavicle,  where  the  first  rib  crosses  it.  The  arch 
of  the  subclavian  artery  should  be  identified;  it 
also  crosses  the  clavicle  at  about  its  middle.  Be- 
3^ond  lies  the  apex  of  the  pleura,  hidden  by  the 
plexus.      Still    further,    at    the    external    border    of 


ANESTHESIA  OF  THE  EXTREMITIES. 


235 


the  sterno-cleido-mastoid,  will  be  noticed  the  scale- 
nus anticus,  as  well  as  the  omo-hyoid,  ascending 
obliquely  from  the  first  rib,  and  which  has  been 
divided,  in  order  the  better  to  show  the  course 
of  the  rib.  Figure  176  shows  the  parts  as  they 
present   themselves   after   removal   of   the   skin   and 


Fig.  176. — Anesthesia  of  the  upper  extremity.  (Pauchet.) 
A,  omo-hyoid.  B,  brachial  plexus.  C,  subclavian  artery.  D, 
scalenus  anticus.    E,  sterno-cleido-mastoid. 


the  superficial  and  deep  fascia.  The  transversalis 
artery  of  the  neck  is  seen  crossing  the  nerve 
trunks  closely  superimposed.  Figure  177  and  those 
following  show  the  direction  the  needle  should 
take.  According  to  the  more  or  less  oblique 
direction  of  the  first  rib  from  the  spine  to  the 
sternum,  the  needle,  if  prolonged,  should  reach 
the  spinous  process  of  the  second  or  the  third 
dorsal  vertebra.  On  the  other  side  are  shown 
the  plexus,  the  artery,  the  insertion  of  the  scaleni, 
and    finally,    immediately    below    the    clavicle,    the 


2Z6 


REGIONAL   ANESTHESIA. 


crescent  constituted  by  the  nerves  surrounding  the 
artery.  A  needle  introduced  close  to  the  artery 
and  properly  directed  should  pass  through  the 
middle  of  the  nerve  plexus.  Almost  always  the 
pulsations  of  the  artery  will  be  transmitted  to  it. 
The  narrowness  of  the  interval  between  the 
scaleni   is   also   apparent. 


A     6  «• 


Fig.  177. — Anesthesia  of  the  brachial  plexus.  (Kulen- 
.)  Summit  of  the  thorax.  Direction  of  the  needle  to 
the  left.  To  the  right,  relationship  of  the  structures  in  the 
vicinity.  A,  subclavian  vein.  B,  insertion  of  the  scalenus  an- 
ticus.  C,  subclavian  artery.  D,  brachial  plexus.  E,  insertion 
of  the  scalenus  posticus. 


TECHNIQUE     OF    THE     INJECTION. 

The  patient  should,  if  possible,  be  placed  in 
the  sitting  posture  (Fig.  178),  and  should  be 
forewarned  of  the  paresthesia  radiating  to  the  fin- 
gers that  will  occur  when  the  needle  touches  the 
plexus,  being  requested  to  make  known  the  moment 
when  it  appears.  The  subclavian  artery  is  now 
slightly    palpated    with    the    finger.      Its    pulsations 


OPERATIONS    UPON   THE   EXTREMITIES. 


237 


are  often  visible,  especially  on  the  right  side. 
Just  outside  of  the  point  where  the  artery  descends 
behind  the  clavicle,  with  a  fine  needle,  a  wheal  is 
made,  which  will  correspond  without  exception  to 
the  middle  of  the  clavicle.  The  external  jugular 
vein,  often  visible  lower  down,  crosses  the  clavicle 


Fig.  178. — Supraclavicular  anesthesia  of  the  brachial  plexus. 
(Kulenkampff.)  The  left  index  finger  locates  and  protects 
the  subclavian  artery.  Laterally  to  the  artery  and  above  the 
middle  of  the  clavicle,  (X),  the  needle  is  introduced  in  the 
direction  of  the  spinous  process  of  the  third  dorsal  vertebra. 


at  the  same  point.  Through  this  wheal  a  fine 
needle  4  to  6  centimeters  long  is  inserted  and 
directed  as  if  one  desired  to  strike  the  spinous 
process  of  the  second  or  third  dorsal  vertebra.  The 
plexus  is  superficially  situated  under  the  aponeu- 
rosis. As  soon  as  the  needle  strikes  it,  lancinat- 
ing pains  occur  in  the  fingers  supplied  by  the 
median,    which    is    the    most    superficial,    and    the 


238  REGIONAL   ANESTHESIA, 

radial,  situated  behind  the  median.  If  the  first 
rib  is  encountered  at  a  depth  of  from  i  to  3 
centimeters,  the  operator  will  know  that  he  has 
missed  and  passed  the  plexus,  as  it  is  more  super- 
ficially  placed.      If   no   paresthesia   is   produced,   he 


Fig.  179. — Blocking  the  brachial  plexus.  (Pauchet.)  The 
needle  penetrates  the  skin  above  and  close  to  the  clavicle.  It 
traverses  the  plexus  at  the  level  of  the  clavicle  and  its  point 
touches  the  first  rib.  If  the  line  of  direction  were  prolonged  it 
M^ould  pass  through  the  spinous  process  of  the  third  dorsal 
vertebra. 


should  try  to  provoke  it  by  altering  the  position 
of  the  needle.  Very  often,  fear  of  wounding  the 
artery  causes  the  operator  to  introduce  the  needle 
too  far  out.  If  blood  comes  from  the  needle,  it 
is  because  a  vein  or  artery  has  been  pierced,   and 


ANESTHESIA  OF  THE  EXTREMITIES.  239 

its  direction  must  be  changed.  The  moment  pares- 
thesia appears,  the  syringe  is  adapted  to  the 
needle  and  lo  mils  of  the  2  per  cent,  solution 
injected.      If   paresthesia    is   produced    only    in    the 


Fig.  180. — Blocking  the  brachial  plexus.  (Pauchet.)  The 
needle  is  inserted  just  above  the  middle  of  the  clavicle.  The 
left  index  finger  locates  the  pulsations  of  the  artery  and 
pushes  it  out  of  the  way.  Abduction  of  the  arm  to  45°  (Louis 
Bazy)  lifts  avi^ay  the  artery  and  forms  a  curve  with  its  con- 
cavity directed  upwai-d.  The  needle  points  toward  the  spin- 
ous process  of  the  third  dorsal  vertebra.  It  passes  through  the 
plexus  and  strikes  the  first  rib. 


territory  of  the  median,  part  of  the  solution  should 
be  injected  some  millimeters  more  deeply.  The 
needle  should  be  slightly  displaced  and  10  mils 
injected    in    the    immediate    vicinity.       Under    no 


240  REGIONAL   ANESTHESIA. 

circumstances   should  the   injection  be  made  before 
production  of  the  paresthesia. 

If  unquestionable  paresthesia  has  been  obtained 
both  in  the  territory  of  the  median  and  that  of 
the  radial  in  from  one  to  three  miniites  a  com- 
plete motor  and  sensory  paralysis  will  be  estab- 
lished in  the  arm.  Often  one  must  wait  from 
ten  to  fifteen  minutes.  If,  at  the  end  of  this  time, 
paralysis  is  not  complete,  5  to  lo  mils  of  the  4 
per  cent,  solution  may  be  injected.  Success  will 
then,  however,  be  uncertain.  After  the  injection, 
the  tourniquet  may  be  applied  without  pain.  It  is 
often  useful,  for  after  blocking  of  the  brachial 
plexus  the  arm  is  habitually  hyperemic,  the  vaso- 
motors being  paralyzed  as  after  section  of  the 
nerves.  The  motor  paralysis  always  reaches  the 
circumflex  nerve;  but  its  territory  is  only  hypo- 
esthetized  or  uninfluenced.  Other  nerves,  prob- 
ably filaments  from  the  supraclavicular,  take  part 
in  the  innervation  of  this  region.  The  anesthesia 
lasts  from  one  hour  and  a  half  to  three  hours. 


ANESTHESIA     OF      THE      BRACHIAL      PLEXUS      BY      THE 
INFRACLAVICULAR    ROUTE LOUIS    BAZY. 

The  brachial  plexus  assumes  the  shape  of  a 
fan,  the  axis  of  which  is  constituted  by  the 
seventh  cervical  nerve.  The  origin  of  this  root 
is  immediately  below  the  anterior  tubercle  of  the 
transverse  process  of  the  sixth  cervical  vertebra 
(tubercle  of  Chassaignac).  It  is  found  on  a  level 
with   the   inferior   border   of   the   cricoid   cartilage. 


ANESTHESIA  OF  THE  EXTREMITIES. 


241 


The  tubercle  of  Chassaignac  is,  then,  the  first 
landmark. 

After  grouping  themselves  around  the  seventh 
cervical,  the  other  branches  of  the  cervical  plexus 


Fig.  181. — Infraclavicular  anesthesia  of  the  brachial  plexus. 
(Pauchet.)  Amputation  of  the  arm  performed  on  the  Meuse 
at  a  spot  6  kilometers  from  the  firing  line.  The  operating 
room  had  been  set  up  by  the  ambulance  orderlies.  Surgeon : 
Sourdat.  Assistant :  Louet,  auxiliary  physician.  The  patient 
is  looking  toward  the  camera. 


become  engaged  in  the  space  between  the  clavicle 
and  the  first  rib,  and  afterward  pass  perpendicu- 
larly to  the  coracoid  process.  When  the  arm  is 
abducted   in   such   a   way  that   the   tangent   passing 

16 


242 


REGIONAL   ANESTHESIA. 


Line  of  cricoid  'with  Wcenical 
Cricoid 


Fig.  182. — Anesthesia  of  the  brachial  plexus  by  the  infraclavicular 
route.  (Paiichet.)  Observe  that  the  cricoid  cartilage  corresponds  to 
the  transverse  procees  of  the  sixth  cervical  (tubercle  of  Chassaignac). 
This  tubercle  may  be  found  by  palpation,  and  the  assistant  should 
place  his  index  finger  there  at  the  time  of  the  injection.  To  the  right, 
the  coracoid  process,  and  one  fingerbreadth  within  it,  the  plexus.  The 
operator  introduces  the  needle  here  immediately  below^  the  clavicle  and 
directs  it  toward  the  tubercle  of  Chassaignac.  The  arm  having  been 
abducted  to  45°,  the  axillary  artery  is  separated  from  the  brachial 
plexus,  drawn  away  by  the  two  thoracic  branches  given  off  from  its 
lower  aspect.    The  artery  rests  on  the  iirst  rib. 


ANESTHESIA  OF  THE  EXTREMITIES.  243 

through  the  apex  of  the  coracoid  process  strikes 
the  tubercle  of  Chassaignac,  this  hne  indicates  ex- 
actly the  direction  of  the  brachial  plexus,  which 
is  situated  one  finger-breadth  below  it.  This  line 
may  be  considered  as  the  "line  of  anesthesia," 
and  the  coracoid  process  constitutes  the  second 
landmark.  In  this  position  the  arm  forms  with 
the  trunk  an  angle  of  45°  (Fig.  184).  The  axil- 
lary artery,  held  against  the  arm  by  its  acromio- 
thoracic  branch,  deviates  from  the  brachial  plexus, 
describing  a  curve  with  its  concavity  upward.  As 
a  result  of  this,  the  risk  of  wounding  it  is  slight. 

TECHNIQUE    OF    THE    INJECTION. 

The  patient  is  placed  upon  the  table,  with  his 
spinal  column  resting  upon  a  cushion  in  such  a  way 
that  his  shoulders  are  arched,  as  though  for  liga- 
tion of  the  subclavian  or  axillary  under  the  clav- 
icle. The  arm,  hanging  and  abducted  to  45°,  ren- 
ders the  prominence  of  the  coracoid  more  appar- 
ent,  and   the   plexus   more   superficial. 

The  operator  places  himself  on  the  side  to  be 
operated  upon,  between  the  arm  and  the  trunk. 
He  locates  the  apex  of  the  coracoid  and  im- 
mediately within  it,  with  the  left  index  finger, 
he  depresses  the  soft  tissues,  as  though  wish- 
ing to  make  more  apparent  the  prominence  of  the 
coracoid. 

Meanwhile  the  assistant  identifies  the  tubercle 
of  Chassaignac,  over  which  he  places  his  index 
finger.      The   arm   being   abducted   to   45°,    the   in- 


244 


REGIONAL   ANESTHESIA. 


Fig.  183. — Anesthesia  of  the  brachial  piexus  by  the  infraclavicular 
route.  (Louis  Easy.)  The  two  hands  show  the  "line  of  anesthesia." 
The  finger  of  an  assistant  is  placed  on  the  tubercle  of  Chassaignac  ; 
the  surgeon's  finger,  inside  of  the  coracoid  process,  which  is  shown  by- 
dotted  lines.  Here,  within  the  finger  tip,  the  needle  enters  immediately 
below  the  clavicle  and  is  directed  toward  the  brachial  plexus.  It  is 
well  to  inject  both  upward,  to  the  right,  to  the  left,  and  deeply  down- 
ward to  be  sure  of  reaching  all  the  branches  of  the  plexus. 


ANESTHESIA  OF  THE  EXTREMITIES.  245 

dex  finger  of  the  operator  and  that  of  his  assist- 
ant face  each  other,  and  the  interval  separating 
them  marks  the  course  of  the  plexus  (Fig.  183). 
The  line  of  anesthesia  is  now  traced  upon  the 
skin   with   ^    per   cent,    procaine-adrenin    solution. 

A  needle  9  centimeters  long  is  introduced  in 
the  zone  of  infiltration,  almost  immediately  below 
the  clavicle.  The  needle  is  pointed  in  such  a  way 
that  it  grazes  the  posterior  border  of  the  bone. 
When  the  needle  has  passed  slightly  beyond  the 
upper  surface  of  the  clavicle,  10  mils  of  2.5  per 
cent,  procaine-adrenin  solution  are  injected.  The 
arm  is  flexed  as  if  one  wanted  to  place  it  upon 
the  chest.  As  a  result  of  this  maneuver  the  bra- 
chial plexus  is  relaxed  and  comes  in  front  of  the 
needle,  when  it  can  be  directly  penetrated  and 
anesthetized. 

Operations  upon  the  Hand. 

The  technique  of  anesthetizing  a  finger  by 
means  of  injections  all  round  it  under  the  skin  of 
the  first  phalanx  has  been  well  described  by  Rec- 
lus  and  is  too  well  known  to  require  description 
anew.  The  adjacent  parts  of  the  metacarpus  may, 
however,  be  anesthetized  consentaneously  with  the 
finger. 

anestiip:sia   of   a   finger   with    the   adjacent 
portion  of  the   metacarpal. 

Two  wheals  are  made  upon  the  dorsal  surface 
of    the    interdigital    space,    corresponding   to    its    in- 


246 


REGIONAL   ANESTHESIA. 


Fig.  184. — Landmarks  for  injection  of  the  fingers.  (Pau- 
chet.)  The  pyramid  A  shows  the  depth  to  which  the  needle 
is  introduced,  as  ilkistrated  in  Fig.   187. 


Fig.   185. — Manner   of   holding  the   syringe   in  infiltrating  the 
palm  by  injection  into  the  interdigital  spaces. 


ANESTHESIA  OF  THE  EXTREMITIES. 


247 


ternal  and  external  borders  (Fig.  184).  A  J/^  or 
I  per  cent,  solution  is  freely  injected  under  the 
skin  in  the  direction  of  points  A  or  D  in  the 
palm,  and  B  or  C  in  the  back  of  the  hand.  Fig. 
185  shows  the  course  of  the  needle  in  an  injection 
in  the  palm  through  the  interdigital  space.  The 
operation  should  not  be  started  until  the  anes- 
thesia has  reached  the  tip  of  the  finger. 


DISARTICULATION     OF     THE     MIDDLE     FINGER OPERA- 
TION    UPON     THE    THIRD     METACARPAL     BONE. 

Four  wheals   are  made    (Fig.    186),  two   in  the 
interdigital    spaces,    and    two   metacarpal,    over    the 


Fig.  186. — Anesthesia  of  the  medius  with  the  head  of  its 
metacarpal;  also  anesthesia  of  the  thumb  with  its  metacarpal. 
(Pauchet.) 


interosseous  spaces.  The  start  is  made  at  points 
3  and  4.  Fig.  189  shows  a  section  of  the  meta- 
carpus   and    the    course    followed    by    the    needle. 


248 


REGIONAL   ANESTHESIA. 


Fig.  187. — Infiltration  of  the  palm  of  the  hand  through  two 
injections  from  the  dorsal  aspect.     (Pauchet.) 


Fig.  188. — Same  as  the  preceding. 


ANESTHESIA  OF  THE  EXTREMITIES.  249 

The  tip  of  the  left  index  finger  being  placed  in 
the  patient's  palm,  the  needle  is  introduced  at  3 
and  4,  and  the  injection  made  perpendicularly 
through  the  interosseous  space  until  the  tip  of  the 
needle  shows  under  the  skin  of  the  palm  at  B 
(Figs.    187    and    188).      At   each    one   of    the   two 


Fig.  189. — Anesthesia  of  a  finger  and  its  metacarpal  bone. 
(Pauchet.)  Longitudinal  section  of  an  interosseous  space 
showing  the  different  directions  that  the  needle  should  take. 
1,  deep  palmar  arch ;  2,  superficial  palmar  arch ;  3,  ulnar  nerve ; 
4,  palmar  aponeurosis. 


injections  5  mils  of  the  ^  per  cent,  solution  are 
used.  Next  one  infiltrates  subcutaneously  from 
points  I  and  2,  in  the  palm  toward  point  B,  and 
upon  the  dorsum  toward  3  and  4.  Finally  points 
3  and  4  are  united  by  a  subcutaneous  injection. 
In  all,  from  30  to  40  mils  of  the  ^  per  cent, 
solution  are  required. 


250  REGIONAL   ANESTHESIA. 

DISARTICULATION     OF     THE     THUMB     WITH 
ITS     METACARPAL. 

The  interosseous  space  is  first  injected,  start- 
ing from  point  6  and  introducing  the  needle  to 
point  A  under  the  skin  of  the  palm  (Fig.  i86). 
Owing  to  the  thickness  of  the  soft  parts,  lo  mils 
of  the  ^  per  cent,  solution  are  required.  The  next 
injection  is  made  subcutaneously  from  points  5  and 
7  toward  the  palm  in  A,  upon  the  back  of  the 
hand  from  6.  About  50  mils  of  the  3^  per  cent, 
solution  are  used.  The  thenar  eminence  may  thus 
be  anesthetized  without  piercing  the  skin  of  the 
palm,  which  is  very  sensitive.  The  same  pro- 
cedure may  be  followed  for  the  fifth  metacarpal 
and   finger. 

ANESTHESIA    OF    SEVERAL     FINGERS    WITH 
THEIR     METACARPALS. 

Injections  made  at  points  i,  2,  and  3  (Fig.  190) 
anesthetize  the  second  and  third  fingers.  From 
point  2  the  injection  is  pushed  in  the  interosseous 
space  against  point  A,  and  from  points  i  and  3 
in  the  palm  toward  point  A.  On  the  back  of  the 
hand  one  infiltrates  under  the  skin  toward  point  2. 
Injections  made  at  4,  5,  and  6  anesthetize  the 
third  and  fourth  fingers.  Portions  of  the  meta- 
carpus may  be,  as  desired,  circumscribed  in  the 
anesthetized  territory,  according  as  the  points  of 
entry  2  or  6  are  placed  nearer  the  fingers  or  the 
wrist.  About  50  mils  of  ^  per  cent,  solution 
are  required. 


ANESTHESIA  OF  THE  EXTREMITIES. 


251 


Fig.  190. — Anesthesia  of  two  fingers  with  the  heads  of  the 
metacarpal  bones.      (Pauchet.) 


Fig.  191. — Anesthesia  of  one  finger  with  the  head  of  its 
metacarpal.  (Pauchet.)  Injections  are  made  along  the  dotted 
lines  through  wheals  at  1  and  2,  circumscribing  the  region  to 
be  operated  upon. 


252 


REGIONAL   ANESTHESIA. 


ANESTHESIA    OF    THE    SOFT    PARTS    OF    THE    PALM. 

Any   portion   of   the   palm   may   be   anesthetized 
by  employing  the   same  technique   as   already   des- 


Fig.  192. — Anesthesia  of  a  portion  of  the  palm  of 
the  hand.     (Pauchet.) 


Fig.  193. — Lines  of  infiltration  for  minor  operations  upon 
the  dorsal  aspect  of  the  hand.     (Pauchet.) 


cribed  for  anesthesia  of  the  thenar  and  hypothe- 
nar  eminences,  e.g.,  in  disarticulation  of  the  thumb. 
The    needle    should,    however,    always    be    entered 


ANESTHESIA  OF  THE  EXTREMITIES.  253 

Upon  the  borders  of  the  hand  and  upon  the  dor- 
sal aspect  of  the  interosseous  spaces  (Fig.  192). 
If  it  is  desired  to  anesthetize  the  pahii  above  the  in- 
dex finger  (Figs.  191,  193).  the  wheals  should  be 
made  at  points  i  and  2.  Through  these  two 
points,  free  injections  are  made  toward  point  A 
in  the  palm,  using  30  to  40  mils  of  the  >4  per 
cent,  solution.  In  the  case  of  phlegmons  of  the 
hand,  one  should  not  inject  in  the  vicinity  of  the 
affected  parts,  but  resort  instead  to  anesthesia  of 
the  brachial  plexus. 


ANESTHESIA     OF     THE    SOFT     PARTS     OF    THE 
BACK    OF    THE    HAND. 

In  anesthesia  instituted  for  the  treatment  of 
wounds  or  for  the  extirpation  of  ganglions,  cysts, 
and  other  tumors,  the  field  of  operation  is  sur- 
rounded with  a  y2  per  cent,  solution.  Fig.  193 
shows  the  manner  in  which  the  infiltration  should 
be  conducted  in  different  cases.  All  that  is  neces- 
sary is  to  surround  three  sides  of  the  field  in  the 
form  of  a  U,  since  the  nerves  descend  from  the 
forearm  exclusively.  The  anesthesia  reaches  the 
periphery  by  reason  of  the  injection  of  three  sides 
and  in  some  cases  extends  beyond  it  below  the 
field  of  operation.  If  the  injections  be  made  first 
under  the  tendons,  and  then  under  the  skin,  the 
anesthesia  will  include  tissues  beneath  the  fascia. 


254 


REGIONAL    ANESTHESIA. 


ANESTHESIA    OF    THE    ULNAR    NERVE 
AT    THE    ELBOW. 

The  ulnar  nerve  is  ordinarily  palpable  above 
the  epitrochlea,  where  it  can  be  made  to  roll  under 
the  finger.  In  anesthesia  it  is  fixed  with  the 
thumb  and  index  finger  of  the  left  hand  and  the 
needle  is  pushed  up  to  it  through  the  subcuta- 
neous tissues  and  fascia.  The  moment  the  nerve 
is   touched,   the  patients   will   feel   and   complain   of 


Fig.  194. — Section  of  the  forearm  above  the  wrist.     (Pauchet.) 
1,  Palmaris  longus.     2,  Median  nerve.     3,  Ulnar  nerve. 


the  same  tingling  as  is  experienced  when  the 
nerve  is  compressed.  The  solution  is  then  in- 
jected. It  should  be  noted  that  in  many  patients 
the  ulnar  nerve,  when  the  arm  is  flexed,  is  sit- 
uated not  behind  but  in  front  of  the  epitrochlea, 
and  passes  behind  only  when  the  forearm  is  in 
extension.  Anesthesia  follows  very  quickly  after 
the  injection  and  involves  the  little  finger,  the  hy- 
pothenar  eminence,  the  ulnar  border  of  the  hand, 
and    the    fifth    metacarpal.      For    disarticulation    of 


ANESTHESIA  OF  THE  EXTREMITIES. 


255 


the  little  finger  and  other  operations  in  this 
region,  there  is  no  simpler  procedure  (Figs.  195 
and   196). 


ANESTHESIA    OF    THE    ENTIRE    HAND. 

The  hand  receives^  from  the  forearm  the  ulnar, 
median    and    interosseous    nerves,    which    are    all 


Fig.  195. — Anesthesia  of  the  uhiar  nerve.  (Pauchet.)  The 
nerve  trunk  is  infiltrated  in  the  depression  between  the  epi- 
trochlea  and  the  olecranon  process.  1.  Ulnar  nerve.  2.  Fibrous 
arch.     3.  Flexor  carpi  ulnaris. 

three  subfascial,  together  with  the  endings  of  the 
radial,  which  are  subcutaneous.  Fig.  198  presents 
a   perpendicular    section   of   the    forearm   above   the 


2S6 


REGIONAL   ANESTHESIA. 


Fig.  196. — Anesthesia  of  the  ulnar  nerve  at  the  elbow.  (Pauchet.) 
Anesthesia  has  been  induced  by  means  of  an  injection  of  strong  pro- 
caine-adrenin  solution  in  the  depression  between  the  epitrochlea  and 
the  olecranon,  as  well  as  by  a  bracelet  of  subcutaneous  infiltration  at 
the  bend  of  the  elbow.  Suture  of  the  ulnar  nerve  has  been  com- 
pleted. The  dissection  of  the  nerve  has  been  effected  without  any  pain. 
The  wound  is  sutured  with  silkworm  gut. 


ANESTHESIA  OF  THE  EXTREMITIES. 


257 


Fig.  197. — Points  of  introduction  oi  the  needle  to  reach  the 
median  and  uhiar  nerves  above  the  wrist.  The  needle  is 
pointed  and  the  injections  made  in  the  direction  of  the  arrows. 


Fig.  198. — Anesthesia  of  the  hand.  (Pauchet.)  Transverse 
section  of  the  wrist  at  the  level  of  the  inferior  radiocarpal 
articulation.  Note  the  bracelet-like  black  line  of  subcutaneous 
infiltration.  The  arrows  represent  the  deep  injections  intended 
for  A,  the  median  nerve,  and  C,  the  ulnar  nerve.  1.  Tendon 
of  the  palmaris  brevis.  2.  Tendon  of  the  palmaris  longus.  3. 
Tendon  of  the  abductor  longus  pollicis.  4.  Supinator  longus. 
5.  Flexor  carpi  ulnaris.  6.  Ulnar  artery.  7.  Ulna.  8.  Radius. 
9.  Pronator  quadratus.     10.  Radial  artery. 

17 


258  REGIONAL   ANESTHESIA. 

wrist,  showing  the  direction  in  which  the  needle 
should  be  pushed  toward  the  median  and  ulnar 
nerves.  To  reach  the  median  at  this  level,  a 
wheal  is  made  on  the  ulnar  side  of  the  tendon 
of  the  palmaris  longus,  and  the  needle  pushed 
through  the  fascia  under  this  tendon.  The  oper- 
ator attempts  to  touch  the  nerve  with  the  needle 
point.  When  the  patient  complains  of  shooting 
pains,  5  mils  of  a  2  per  cent,  solution  are  in- 
jected. Next,  5  mils  of  the  same  solution  are 
injected  on  the  ulnar  side  of  the  forearm,  above 
the  pisiform  and  beneath  the  tendon  of  the  flexor 
carpi  ulnaris  (Fig.  198).  Finally,  one  infiltrates 
through  two  or  three  other  points  in  ring  fashion 
around  the  forearm — under  the  skin,  then  upon 
the  dorsal  surface  under  the  fascia  between  the 
tendons,  and  up  to  the  interosseous  ligament, 
using  50  to  60  mils  of  a  ^  per  cent,  solution. 
Complete  anesthesia  of  the  whole  hand  is  ob- 
tained in  from  ten  to  fifteen  minutes.  This  pro- 
cedure  is    simpler   than    intravenous    anesthesia. 

Operations  upon  tpie  Forearm. 

The  skin  and  subcutaneous  tissues  of  the  fore- 
arm down  to  its  lower  third  are  exclusively  sup- 
plied by  long  subcutaneous  nerves  that  emerge 
from  under  the  fascia  above  the  elbow.  Infiltra- 
tion of  a  transverse  band  of  subcutaneous  tissue 
on  the  forearm  produces,  therefore,  an  anesthesia 
that  becomes  more  or  less  extensive  below  the 
level   of   injection,    and   when    a   circle   of   subcuta- 


ANESTHESIA  OF  THE  EXTREMITIES. 


259 


neous  tissue  above  or  below  the  elbow  is  infil- 
trated, the  anesthesia  extends  on  all  aspects  to  the 
lower   third  of  the   forearm. 

For  operations  upon  the  skin  of  the  upper  two- 
thirds  of  the  forearm,  the  field  of  operation  should 
be   surrounded  by  injections   disposed  in  the  shape 


Fig.  199. — Anesthesia  of  the  dorsal  surface  of  the  fore- 
arm and  hand.     (Pauchet.) 


of  a  U  with  its  concavity  directed  downward, 
using  the  }^  per  cent,  solution  (Fig.  199).  The 
unilateral  nerve  supply  of  this  region  renders  the 
muscular  injection  unnecessary  if  the  operation  is 
unilateral. 

In   the  lower   third  the  injection  should  also  be 
subfascial    on    account    of    the    nerves    that    emerge 


260  REGIONAL   ANESTHESIA. 

from  within  the  forearm.  Extensive  areas  upon 
the  lower  third  of  the  dorsal  aspect  of  the  fore- 
arm may  be  anesthetized  as  follows:  Two  in- 
jections are  made  upon  the  borders  of  the  fore- 
arm, indicated  by  the  bony  ridge  of  the  radius  and 
ulna  (Fig.  igg,B).  With  a  long  needle  the  soft 
parts  of  the  dorsal  surface  are  infiltrated,  begin- 
ning with  the  muscles,  then  the  subcutaneous  tis- 
sues transversally,  with  40  or  50  mils  of  a  ^2 
per  cent,  solution.  From  these  two  points  the 
subcutaneous  infiltration  descends  to  the  wrist  and, 
if  necessary,  to  the  fingers.  This  procedure  is 
useful  for  the  treatment  of  severe  wounds  of 
the  soft  parts,  the  extirpation  of  tumors  or  cysts, 
tuberculosis  of  the  tendon  sheaths,  etc. 

The  procedure  adapted  for  the  lower  half  of 
the  anterior  surface  of  the  forearm  dififers  slightly 
by  reason  of  the  median  and  ulnar  nerves.  Two 
injections  are  made  upon  the  sides  of  the  forearm, 
and  these  are  joined  by  infiltrating  transversally 
close  to  the  bone  and  the  interosseous  ligament 
at  the  start,  and  then  in  the  subcutaneous  tissue. 
It  is  useless  to  try  to  infiltrate  the  muscles  sep- 
arately; this  is  almost  impossible  in  any  case,  and 
the  median  and  ulnar  are  not  blocked.  If  the 
operative  field  is  in  the  ulnar  distribution,  it  is 
best  to  inject  this  nerve  at  the  elbow.  If  it  is  in 
that  of  the  median,  then  this  nerve  should  be 
anesthetized  at  the  upper  extremity  of  the  incision. 
Those  well  trained  in  anesthesia  of  the  brachial 
plexus  will  give  this  procedure  the  preference — 
especially    in    phlegmons,    operations    on    the    bone, 


ANESTHESIA  OF  THE  EXTREMITIES. 


261 


amputations  and  interventions  upon  the  upper  half 
of  the  forearm,  and  in  fact,  in  all  operations  of 
importance  below  the   shoulder. 

Operations  upon  the  Elbow. 

A  subcutaneoits  U-shaped  infiltration  with  con- 
cavity downward,  using  40  mils  of  a  ^  per  cent, 
solution,  upon  the  dorsal  surface  of  the  elbow, 
and  instituted  through  two  wheals  (Fig.  200), 
will  permit  of  extirpation  of  the  olecranon  bursa. 
To  suture  a  fractured  olecranon,  two  additional 
injections  are  necessary,  3  and  4.  One  begins  by 
injecting  20  mils  of  the  ^   per  cent,   solution  into 


Fig.  200. — Anesthesia  of  the  elbow  region.     (Panchet.) 

the  articulation,  below  the  external  and  internal 
condyles.  Ten  mils  are  injected  under  the  tendon 
of  the  triceps  in  the  muscles  covering  the  ole- 
cranon, first  inside  and  then  outside,  and  finally 
the  U-shaped  subcutaneous  injection  is  made.  For 
an  aseptic  arthrotomy — as  for  the  removal  of  for- 
eign bodies — 20  mils  of  the  ^  per  cent,  solution 
are  injected  in  the  joint  and  the  capsule  and  sub- 
cutaneous tissue  infiltrated  along  the  line  of  in- 
cision. To  perform  a  resection  or  disarticulation, 
blocking   of   the    plexus    is    necessary. 


262 


REGIONAL   ANESTHESIA. 


Fig.  201. — Anesthesia  of  the  upper  extremity.  (Pauchet.) 
A,  Blocking  of  the  brachial  plexus,  producing  anesthesia  of 
the  entire  upper  limb.  B,  Anesthesia  of  the  forearm  and  hand. 
C,  Anesthesia  of  the  hand  only.  The  points  1,  2,  3,  2'  and  3' 
are  the  wheals  through  which  the  subcutaneous  bracelet  of  in- 
filtration is  made.  The  needle  employed  to  infiltrate  deeply  the 
nerve  trunks  is  also  introduced  through  them.  1,  Anterior 
branch  of  the  radial  nerve.  2  and  2',  Median  nerve.  3  and 
3',  Ulnar  nerve. 


ANESTHESIA  OF  THE  EXTREMITIES. 


263 


Operations  upon  the  Arm. 

Local  injections  are  here  suitable  only  for 
superficial  operations.  A  simple  subcutaneous  in- 
jection is  insufficient  by  reason  of  the  irregular 
and  multiple  branching  of  the  nerves.     A  pyram- 


Fig.  202.— Anesthesia  of  the  forearm  and  hand.  (Pau- 
chet.)  Transverse  section  at  the  elbow.  Note  the  bracelet  of 
subcutaneous  infiltration  marked  by  a  heavy  black  line.  A, 
Deep  injection  to  the  median  nerve.  B,  Deep  injection  to  the 
radial.  C,  Deep  injection  to  the  ulnar.  1,  Tendon  of  the  bi- 
ceps. 2,  Supinator  longus.  3,  Pronator  radii  teres.  4,  Exten- 
sor carpi  radialis  longus.  5,  Flexor  carpi  ulnaris.  6,  Brachialis 
anticus.     7,  Brachial  artery. 


idal  injection  of  the  operative  field  is  always  re- 
quired. To  anesthetize  the  skin  of  the  entire  sur- 
face of  the  arm,  as  for  Thiersch  skin  grafting, 
one  infiltrates  superficially  all  the  subcutaneous  tis- 
sue with  a  J/4   per  cent,   solution,  as  for  the  thigh. 


264  REGIONAL   ANESTHESIA. 

For  extensive  operations  on  the  bones,  amputa- 
tions, etc.,  the  plexus  is  injected  above  the  clav- 
icle   (Fig.    i8i). 

Operations  upon  the  Shoulder. 

Large    lipomas    of    the    shoulder    are    easily    re- 
moved  after   multiple   infiltrations   have   been   made 


r/. 


Fig.  203. — Suture  of  a  fracture  of  the  clavicle.  {Pauchet.) 
Through  two  injections  the  clavicle  is  surrounded,  to  any  ex- 
tent necessary,   with   the   anesthetic   solution. 

all  around  them.  The  base  of  the  tumor  is 
reached  with  long  needles,  and  the  injections  are 
connected  with  one  another  by  bands  of  subcuta- 
neous infiltration.  A  ^  per  cent,  solution  is 
used,  and  as  much  as  200  to  250  mils  may  be 
injected. 


ANESTHESIA  OF  THE  EXTREMITIES.  265 

Operations  on  the  shoulder  are  performed  after 
anesthesia  of  the  plexus.  For  shoulder  disarticu- 
lation, the  plexus  has  first  to  be  infiltrated,  and 
then  the  subcutaneous  tissues  at  the  root  of  the 
shoulder  up  to  the  acromion  and  through  the 
axilla.      The   ^    per   cent,    solution   is   used. 

LOWER    EXTREMITY. 

It  is  difficult  to  anesthetize  the  lower  ex- 
tremity by  local  injections,  as  it  receives  its  nerve 
supply  from  many  different  trunks.  On  the  other 
hand,  spinal  anesthesia  is  very  serviceable,  and 
only  a  small  amount  of  procaine-adrenin  solution, 
4  or  5  centigrams,  need  be  used.  The  injection 
is  made  directly  into  the  spinal  canal  of  the  lum- 
bar region.  In  a  large  number  of  cases  regional 
anesthesia  is  absolutely  indicated,  and  succeeds  ad- 
mirably. Thus,  all  operations  on  the  foot — resec- 
tion, amputation,  tenotomy,  suture  of  the  patella, 
operations  for  varicose  veins,  or  on  the  inguinal 
lymphatics,  etc., — may  be  performed  with  complete 
anesthesia  by  the  regional  method.  We  give  pref- 
erence, however,  to  lumbar  spinal  anesthesia  for 
all  major  operations,  such  as  resection  of  the 
knee,  resection  of  the  hip,  and  amputation  of  the 
thigh.  We  probably  practice  three  regional  anes- 
thesias  to   every   spinal. 

The  external  cutaneous  nerve  emerges  from 
under  the  inguinal  ligament  immediately  within  the 
anterior  superior  iliac  spine;  it  descends  in  an  out- 
ward   direction    under    the    fascia    lata,    perforates 


266 


REGIONAL   ANESTHESIA. 


the    fascia,    and    supplies    the     skin.       It    can    be 
reached   two   finger-breadths   within   and  below   the 
anterior   superior   spine    (Figs.   204   and   205). 
The  technique   is   as   follows:      A  dermal  wheal 


Fig.  204. — Injection  of  the  external  cutaneous  nerve  (1) 
and  of  the  anterior  crural  nerve  (2).  (Pauchet.)  1,  Point 
where  the  needle  should  be  introduced  to  reach  the  external 
cutaneous;  the  injection  is  made  in  the  direction  of  the  arrow, 
beneath  the  fascia  and  skin.  2,  Point  of  entrance  of  the  needle, 
perpendicularly  to  the  surface,  to  reach  the  anterior  crural 
nerve. 

is  made  and  the  subcutaneous  connective  tissue 
so  injected  as  to  make  a  transverse  band  5  or  6 
centimeters  wide,  parallel  to  Poupart's  ligament. 
Five  mils  of  the  strong  solution  are  then  injected 
under  the  fascia,  in  the  same  direction  as  the  sub- 
cutaneous   infiltration.      The    middle    of    the    infil- 


ANESTHESIA  OF  THE  EXTREMITIES. 


267 


trated  area   should  be   situated   two  finger-breadths 
within   and  below   the   anterior   superior   spine. 


Fig.  205. — Anesthesia  of  the  external  cutaneous  nerve. 
(Pauchet.)  This  nerve  is  reached  at  a  point  two  finger- 
breadths  within  and  below  the  anterior  superior  spine  of  the 
ilium. 


The  anterior  crural  nerve  is  situated  imme- 
diately outside  of  the  femoral  artery  and  is  cov- 
ered by  a  fibrous  band  (iho-pectineus).  With  the 
left  hand  the  operator  locates  the  pulsations  of  the 


268 


REGIONAL   ANESTHESIA. 


femoral  artery  and  pushes  the  latter  inward.  The 
needle  is  then  introduced  immediately  outside  the 
artery,  just  below  Poupart's  ligament.  Where  it 
comes  in  contact  with  a  solid  band  of  fascia, 
the    latter    is    pierced    and    5    mils    of    the    strong 


Fig.  206. — Anesthesia  of  the  anterior  crural  nerve.  (Pau- 
chet.)  A,  Spine  of  the  pubis.  B,  Anterior  superior  iliac  spine. 
C,  Point  half  way  between  the  two.  The  femoral  artery  is 
located  with  the  finger.  The  needle  is  inserted  one  finger- 
breadth  outside  of  it  to  reach  the  anterior  crural  nerve. 


solution  injected  while  still  advancing  i  centimeter 
deeper.  The  patient  should  show  some  muscular 
contraction  in  the  thigh,  proving  that  the  crural 
nerve  has  been  reached.  The  quadriceps  is  then 
immediately    paralyzed. 

Infiltration   of   the   above   two   nerves   affords   a 
broad    zone    of    anesthesia    which    will    permit    of 


ANESTHESIA  OF  THE  EXTREMITIES.  269 

the   taking   of    Thiersch    grafts    from    an    extensive 
surface   of   skin. 

InfiUration  of  the  great  sciatic  nerve  is  very 
difficuh  and  uncertain.  One  may,  however,  suc- 
ceed in  the  following  manner:  Bearing  in  mind 
that  the  nerve  is  situated  in  the  buttock  at  the 
midpoint  of  a  line  passing  from  the  ischium  to  the 
great  trochanter,  two  deep  injections  are  made, 
the  first  at  a  distance  of  2  centimeters  outside  of 
the  tuberosity  of  the  ischium,  and  the  other  3 
centimeters  within  the  great  trochanter.  Or,  a 
single  injection  may  be  made  at  the  intersection 
of  a  horizontal  line  passing  through  the  upper 
border  of  the  great  trochanter,  and  a  vertical  line 
passing  through  the  external  border  of  the  ischium. 
It  is  indispensable  that  the  patient  should  experi- 
ence a  painful  sensation  in  the  toes.  As  soon 
as  this  pain  is  feU  10  mils  of  the  strong  solution 
are   injected. 

Babitzki  proceeds  as  follows:  The  finger  is 
introduced  in  the  rectum,  the  lower  border  of  the 
great  sciatic  notch  identified,  and  its  contents,  i.e., 
the  nerve,  pushed  outward  while  the  right  hand 
introduces   the  needle  to  meet  the  nerve. 

The  lesser  sciatic  nerve  passes  below  the  glu- 
teal fold  exactly  in  the  middle  of  the  posterior 
surface  of  the  thigh,  immediately  beneath  the  fas- 
cia.     It   is,   therefore,    easily   accessible. 

The  obturator  nerve  is  deeply  situated.  To 
reach  it  with  any  degree  of  certainty  all  of  the 
proximal  internal  surface  of  the  thigh  should  be 
infiltrated  to   a  depth  of   3   or  4  centimeters. 


270  REGIONAL   ANESTHESIA. 

In  operating  on  the  great  trochanter  or  the 
neck  of  the  femur,  desensitization  of  the  nerve 
trunks  of  the  lower  extremity  is  not  sufficient;  one 
must  also  anesthetize  the  branches  of  the  genito- 
crural  and  ilio-inguinal  by  infiltration  of  the  skin 
surrounding  the  root  of   the  extremity. 

Operations  upon  the  Toes. 

The  technique  is  the  same  as  for  the  fingers 
(Figs.  208  and  209).  In  the  case  of  the  big  toe, 
three  injections  are  made,  two  on  the  lateral  sur- 
faces and  one  in  the  middle  of  the  dorsal  surface. 


Fig.  207. — Anesthesia  of   a   toe   through   three    dorsal 
injections.     (Pauchet.) 

A  subcutaneous  ring-shaped  injection  is  made  at 
the  root  of  the  member,  and  4  or  5  mils  of  the 
strong  solution  injected.  For  the  other  toes,  the 
injections  are  made  in  the  inter  digital  spaces 
(Fig.    209). 

Great  Toe — Operations  for  Ingrowing  Toe  Nail 
or  Bunion,  Amputation. — In  disarticulation  of  the 
toe  or  resection  of  the  head  of  its  metatarsal 
bone  for  hallux  valgus,  three  wheals  are  made,  one  on 


ANESTHESIA  OF  THE  EXTREMITIES. 


271 


the  internal  border  of  the  foot,  the  second  a  dorsal 
one,  above  the  first  interosseous  space,  and  the 
third   in   the   first    interdigital    space.      One    injects 


Fig.  208. — Anesthesia  of  the  great  toe  with  the  head  of  its 
metatarsal  bone.      (Pauchet.) 

in  the  interosseous  space,  as  for  the  hand.  The 
needle  is  inserted  in  this  space  until  its  tip  touches 
the  deep  portion  of  the  skin  of  the  sole.  Infiltra- 
tion  is   then   conducted   under   the   skin   from    i    to 


Fi£ 


209. — Anesthesia  of  middle  toe  v/ith  the  head  of 
its   metatarsal  bone.      {Pauchet.) 


3,    following    the    dotted    line     (Fig.    208).      Fifty 
mils  of  the  weak  solution  are  needed. 

Third  Toe. — Operations  on  the  metatarsal  (Fig. 
209). — Four    wheals    are    made    as    in    operations 


272 


REGIONAL   ANESTHESIA, 


Upon  the  hand — two  on  the  dorsal  surface  of  the 
interdigital  spaces,  and  two  on  the  dorsum  of  the 
foot  above  the  second  and  third  interosseous  spaces. 
Through  i  and  2,  anesthetic  sokition  is  injected 
in  the  interosseous  space  until  the  point  of  the 
needle  is  perceived  under  the  skin  of  the  sole, 
then  the  injection  is  continued  under  the  skin  of 
the  dorsum  toward  i  and  2.  Fifty  mils  of  the 
weak   solution   are   required. 


Fig.  210. — Tenotomy  of  the  tendo  Achillis.     (Pauchet.) 
TENOTOMY     OF     THE     TENDO     ACHILLIS. 

A  wheal  is  made  on  each  side,  a  subcutaneous 
diamond  formed  as  shown  by  the  dotted  lines  in 
the  illustration  (Fig.  210),  then  infiltration  prac- 
tised under  the  tendon  itself. 


Operations  upon  the  Entire  Foot. 

The  foot  is  supplied  by  five  trunks:  The  an- 
terior and  posterior  tibial,  the  internal  and  ex- 
ternal saphenous,  and  the  musculo-cutaneous    (Fig. 


ANESTHESIA  OF  THE  EXTREMITIES. 


273 


2ii).  The  posterior  tibial  nerve  is  injected  at 
the  inner  malleolus,  i  centimeter  from  the  tendo 
Achillis  (Fig.  211;  note  the  direction  of  the 
needle).  The  needle  is  introduced  from  behind 
forward   up   to   the   posterior   surface   of   the   tibia. 


Fig.  211. — Nerves  to  be  infiltrated  in  anesthetizing  the  en- 
tire foot.  (Pauchet.)  Section  of  left  leg  above,  the  malleoli. 
For  the  anterior  and  posterior  tibial  a^deep  injection  is  neces- 
sary, and  a  subcutaneous  bracelet  for  the  other  nerves,  viz., 
the  external  and  internal  saphenous  and  the  musculo-cutaneous. 


The  operator  feels  his  way  until  he  produces  a 
lancinating  pain,  and  then  injects  5  mils  of  the 
strong  solution.  The  other  wheals  are  made  at 
the  same  level  around  the  leg.  A  subcutaneous 
bracelet  is  infiltrated,  using  50  to  75  mils  of  the 
weak   solution,   and   the   strong   solution   injected   to 


IS 


274 


REGIONAL   ANESTHESIA. 


block  the  anterior  tibial,  along  the  line  for  liga- 
tion of  the  artery  of  the  same  name.  The  re- 
sulting anesthesia  is  sufficient  for  resections  and 
amputations  in  the  infant  and  adult   (Fig.  212). 


Fig.  212.— Anesthesia  of  the  entire  foot.  {Pauchet.) 
Horizontal  section  of  left  leg  above  the  malleoli.  1,  Tibialis 
anterior.  2,  Extensor  proprius  hallucis.  3,  Extensor  communis 
digitorum.  4,  Tibialis  posterior.  5,  Tendo  Achillis.  6,  Flexor 
proprius  hallucis.  7,  Lateral  peronei.  The  black  band  repre- 
sents a  bracelet  of  subcutaneous  infiltration.  A,  Deep  injection 
for  the  anterior  tibial  nerve.  B,  Deep  injection  for  the  pos- 
terior tibial  nerve. 


Operations  upon  the  Knee. 

For  a  hygroma  of  the  prepatellar  bursa,  four 
wheals  are  made  (Fig.  213),  and  the  subcutane- 
ous  cellular   tissue   in   the   interval   then   infiltrated. 


ANESTHESIA  OF  THE  EXTREMITIES. 


275 


This  procedure  is  also  adapted  for  the  suture  of 
a  fractured  patella.  The  prepatellar  fibrous  tis- 
sues and  the  articular  cavity  itself  are  infiltrated 
in  the  same  way  with  the  strong  solution.  In 
suture  of  the  patella,  however,  150  to  200  mils  of 
the  weak  solution  are  used;  the  greater  part  of 
the   solution  runs   out   after   the   incision. 

For  foreign  body  in  the  knee,  the  foreign  body 
is  first  located  with  the  fingers.      Then,   through  a 


Fig.  213. — Removal  of  the  prepatellar  bursa.     (Pauchet.) 


dermal  wheal,  a  needle  is  introduced,  followed  by 
two  or  three  more,  to  immobilize  the  foreign 
body.  The  skin  overlying  it  is  now  infiltrated, 
the  fascia  likewise,  an  incision  made,  the  foreign 
body  removed,  and  the  wound  sutured.  The  oper- 
ation is  brilliant,  rapid,   and  painless. 

By  the  same  procedure  a  transverse  arthrot- 
omy,  with  section  of  the  ligamentum  patellae  and 
the  lateral  ligaments,  can  very  readily  be  per- 
formed.     We    have    in    this    way    removed    projec- 


276 


REGIONAL   ANESTHESIA. 


tiles  embedded  in  the  femoral  condyles.  Resection 
of  the  condyles  can  also  be  done  in  this  way 
where  the  subject  is  not  too  stout;  but  for  this 
operation  we  prefer  spinal  anesthesia.  The  weak 
solution  suffices  in  all  cases. 


Fig.  214. — Infiltration  of  a  mass  of  tissue  for  arthrotomy 
of  the  knee,  1  and  2.  (Pauchet.)  Above,  anesthesia  of  a  seg- 
ment of  vein. 


OSTEOTOMY     OF    THE     FEMUR. 

Supracondylar  and  subtrochanteric  osteotomies 
may  be  practised  under  local  anesthesia  by  in- 
filtration. On  the  outer  surface  of  the  thigh,  at 
a  height  of  lo  centimeters,  a  subcutaneous  and 
then  a  subfascial  band  is  traced.  Next  the  mus- 
cular mass   is   infiltrated,   down  to   the  bone.     Fin- 


ANESTHESIA  OF  THE  EXTREMITIES.  277 

ally  and  still  by  the  same  route,  a  long  needle  is 
introduced  in  front  of  and  outside  of  the  bone, 
and  the  tissues  freely  infiltrated.  The  resulting 
anesthesia  is  perfect,  the  only  steps  in  the  opera- 
tion that  are  disturbing  to  the  patient  being  the 
breaking  of  the  femur  or  the  blows  of  the  mallet. 
The  same   difficulty  is  experienced   in  all  bone  op- 


Fig.  215. — Section  of  the  thigh  through  its  lower  fourth. 
(Pauchet.)  Manner  in  which  the  injections  should  be  directed 
for  an   osteotomy  of  the   femur. 


erations.  Section  of  a  rib  or  the  removal  of  a 
cranial  flap  are  alike  painless  manipulations,  but 
the  patient  must  be  warned  beforehand  of  the 
sounds  caused  by  section  of  bone  tissue. 


Operations  upon  the  Soft  Parts  of  the  Thigh. 

The  subcutaneous  cellular  tissues  above  the 
lesion  are  infiltrated  in  order  to  block  the  sub- 
cutaneous   nerves.      Next,    one    infiltrates    in    front 


278 


REGIONAL   ANESTHESIA. 


Fig.  216. — Extensive  subcutaneous  infiltration  through 
a  series  of  wheals.     (Pauchet.) 


ANESTHESIA  OF  THE  EXTREMITIES. 


279 


and  behind,  and  when  necessary,  below.  This 
constitutes  our  routine  practice  for  operations  on 
varicose  veins  or  for  inguinal  lymphatic  enlarge- 
ments (see  Figs.  216  and  217).  The  operation 
succeeds    very    well,    but    a    large    amount    of    the 


Fig.  217. — Peripheral   infiltration   of  an   inguinal  lymph- 
node  for  adenitis.     (Pauchet.) 


weak  solution  is  required;  this  entails  no  danger, 
for  a  large  portion  of  the  solution  runs  out 
through  the  incision.  In  the  removal  of  varicose 
veins  we  have  commonly  used  200,  250,  and  even 
300  grams  of  the  weak  solution,  which  is  largely 
eliminated  when  the  wound  is  irrigated  with  hot 
saline   solution. 


280 


REGIONAL   ANESTHESIA. 


ANESTHESIA  OF  THE  EXTREMITIES. 


281 


282 


REGIONAL   ANESTHESIA. 


Figs.  220,  221. — Sacral  anesthesia  of  the  lower  extremity.  (Pau- 
chet.)  The  sacral  trunks,  1  to  4,  require  to  be  injected  if  one  is  to 
obtain  the  areas  of  anesthesia  shown  in  the  sections  5".  Sections  L3 
and  L4  show  the  anesthesia  obtained  by  paralumbar  injection.  Sacral 
anesthesia  of  the  genital  organs  is  conducted  through  the  third  fora- 
men. The  skin  is  anesthetized.  The  reader  will  note  the  numbers  of 
the  sacral  trunks  that  must  be  injected  to  obtain  the  desired  anesthesia. 


CONCLUSIONS. 


Regional  anesthesia  may  be  availed  of  in  80 
per  cent,  of  surgical  operations.  Its  success  de- 
pends upon  the  ability  and  experience  of  the  oper- 
ator, but  the  disposition  and  mental  attitude  of 
the  patient  also  play  an  important  part. 

We  invite  beginners  to  use  it  not  only  in  one 
type  of  case,  but  systematically  in  all  cases,  hold- 
ing themselves  in  readiness  to  use  ethyl  chloride 
to  complete  the  work  where  necessary. 

Cranial  nerve  anesthesia  and  the  paravertebral, 
brachial  plexus,  and  trans-sacral  procedures,  which 
are  most  efficacious,  require  actual  training.  If 
our  advice  to  learners  is  followed,  this  should  not 
take  a  long  time.  Take  a  hat  pin  and  a  skeleton 
and  practice  introduction  into  the  cranial  fora- 
mina, as  well  as  into  the  paravertebral  and  sac- 
ral openings,  in  accordance  with  the  landmarks 
mentioned  in  this  book.  Such  practice  will  re- 
quire one  or  two  hours.  The  same  experimenta- 
tion should  then  be  carried  out  upon  a  cadaver. 
This  will  also  require  about  two  hours  of  practice. 

After  these  two  series  of  experiments,  trials 
may  be  made  upon  the  living   subject. 

For  the  remaining  operations,   trials   should  be 

1  Pauchet-Sourdat-Laboure :     Anesthesie  regionale— Doin,  publisher, 

Paris,  1917. 

(283) 


284  CONCLUSIONS. 

made   with   the  book  by  one's   side,   as   is   done  by 
the   internes    in   my   service. 

Be  gentle,  patient,  and  persevering  in  spite  of 
failures  and  the  aversion  of  certain  patients,  and 
you  will  succeed,  with  signal  benefit  to  most  cases 
and  with  general  advancement  of  surgical  practice. 


INDEX. 


Abdomen,  anesthesia  of,  128,  132, 
144,  162,  175,  220 
exploration  of,  162 
Abdominal     incision,     transverse, 
164 
wall,    anesthesia    of,    132,    144, 
175,  220 
infiltration   of,   162 
Abscess,  interlobar,   158 
of  lung,  158 

operation  for.     See  Phlegmons, 
subphrenic,   158 
Adamantoma  of  lower  jaw,   123 
Adenitis,  cervical,   119,   122 

inguinal,  265,  279 
Adenoma  of  breast,  160 

prostate,  212 
Adrenin,  use  of,   14,   16 
Ala  nasi,  anesthesia  of,  69,  99 
Alveolar  process,    superior,    anes- 
thesia of,  69 
Anal  fistula,  incision  in,  227,  229 
sphincter,     anesthesia     of,     226, 
227 
Anesthesia,  Bazy's  method  of,  240 
circular,  25,  26,  88,  89,  99 
costoiliac,  175 
infiltration,   17,  21,  32 
by  layers,  29 
deep,   29 

general   technique   of,    17 
perineal,  224,  225 
skin  wheals  in,  21 
subcutaneous,  25 
surface,  25 
intraspinal.     See    Spinal. 
Kulcnkampff's   method   of,   234, 
235,  236 


paracostal,  175 
parailiac,  175 

paravertebral,      144,      163,      190, 
283 
cervical,   121-123 
dorsal,  144-147,   153,  158,  161, 

190,  198,  199 
lumbar,     ISO,     168,     169,     190, 
198,  199 
pericostal,  153 
presacral.     See   Sacral, 
regional.      See    Regional    Anes- 
thesia, 
sacral,  202,  207,  282,  283 
anterior,  202,  204,  205,  221 
pre-,  202,  204,  205,  221 
trans-,  203,  204,  207,  210-212, 
219,  222,  224,  229,  283 
spinal,    128,    133,    135,    136,   265, 
276 
complications  of,  133 
indications   for,   128,  265,  276 
mortality  in,  134 
regions  influenced   in,   135 
transsacral.     See   Sacral. 
Anesthetics     for     regional     anes- 
thesia,   14,    15,    16 
Anterior  crural  nerve,  266-268 
Anterior    sacral    anesthesia,    205, 

221 
Anterior  tibial  nerve,  272-274 
Antrum  of  Highmore,  anesthesia 

of,  70,  83 
Anus,  anesthesia  of,  132,  182,  211, 
224,  225 
trans-sacral,  224 
artificial,  182 
operations    on,    224 

(285) 


286 


INDEX, 


Anus,  perineal  infiltration  in  oper- 
ations on,  224,  225 

Appendectomy,   143,  163,  169,   170, 
171,   175,  176 

Arm,  anesthesia  of,  232,  240,  241, 
258-264 
amputation  of,  241,  261,  264 

Armamentarium   for   regional  an- 
esthesia,  12,   14 

Arthrotomy  of  elbow,  261 
knee,  275,  276 

Ascending  colon,  operation  on,  175 

Ascites,    evacuation    of    tubercul- 
ous,  167 

Asepsis  in  regional  anesthesia,  18 

Auditory     meatus,     anesthesia    of 
external,   87 
furuncle  in,  88,  91 
exostosis  in,  88 

Auriculo-temporal  nerve,  88 

Auricular   branch   of   pneumogas- 
tric,  88 

Axilla,  anesthesia  of,  153,  162 

Babitski's  method,  269 

Base  of  the  orbit,  58 

Bazy's  method,  240 

Biliary    passages,    anesthesia    of, 

140,  141,  144,  145,  199 
Bladder,    anesthesia    of,    211-213, 
219 

exploration  of,  213 

operations  on,  212 
Bonain's  solution,  86,  99 
Brachial     plexus,     anesthesia     of, 
233-236,  253,  260,  261,  265 

Bazy's  method,  240 

by  w^ay  of  axilla,  233 

infraclavicular,  240 

Kulenkampff's    method,    234-236 

supraclavicular,  234-236,  264 
Brain  tumors,  removal  of,  82 
Breasts,    operations    on,    145,    160, 
161 


Broad     ligament,     infiltration     of 

base  of,  224 
Buccal  nerve,  72 
Buccinator  nerve,  96 

gingival  branches   of,   96 
Bunion,  operation    for,  270 
Bursa,  olecranon,  removal  of,  261 
Bursitis,      prepatellar,      operation 

for,  274-275 

Cancer  of  breast,  161 

floor  of  mouth,  106,  107 

ileocecal  segment,  170 

jaw,  104 

larynx,    122 

palate,  54 

pharynx,    107 

rectum,  163,  212,  213,  229 

stomach,   182 

tonsils,  54,  107 

uterus,  136,  168 
Canine    fossa,   infiltration   of,  83 

teeth,   anesthesia   of,   69,  95,  96 
Carotid  artery,  ligation  of  exter- 
nal,   119 
Cataract  operation,  93 
Catheterization,      anesthesia     for, 

212 
Cecostomy,  170,  172,  175 
Cecum,    anesthesia    of,    145,    163, 
170-172,  175 

operations  on,  163,  170-172,  175 
Celiotomy,  supraumbilical,  65,  167 
Cerebellum,  exposure  of,  46 
Cervical  adenitis,  119 

nerve  roots,  infiltration  of,   109 

plexus,  anesthesia  of.   111,   119 
Cesarean  section,  168 
Chassaignac's    tubercle,    240,    241, 

243 
Cheek,  anesthesia  of,  66,  99,  107 

transverse  incision  of,  107 
Chin,  anesthesia  of,  101 
Cholecystectomy,   199 


INDEX. 


287 


Cholecystotomy,  129 
Choledochotomy,  163 
Ciliary  ganglion,  anesthesia  of,  91 

nerves,  92 
Circular  anesthesia,  25,  26,  88,  89, 

"^ 
Circumcision,  218 
Clavicle,    suture    of    fracture    of, 

264 
Colon,    ascending,    operations    on, 
163,    175 

transverse,   179 
Colporrhaphy,  223 
Colpotomy,  223 
Compound  skull  fracture,  40 
Condyles  of   femur,  275 
Cord,     spermatic,     anesthesia     of, 

197,  214,  215 
Corpora  cavernosa,  anesthesia  of, 

218 
Costal  resection,  153-157 
Costo-chondrites,  suppurative,  158 

iliac  anesthesia,  175 
Couzard  and  Chevrier,  117 
Cranial  operations,  37 
Craniectomy    for   sarcoma,   39 
Crile,  17 
Curettage,  aural,  91 

uterine,  212 
Cutaneous    nerve,    external,    265- 

267 
Cyst  of  dorsum,  253 

floor  of  mouth,   106,   107 

sternum,  143 

uterus,  212 
Cystocele,  213 
Cystotomy,    168,   211 
Cystotomy,  suprapubic,  212,  214 

Danys,  114,  142 
Decompression,  43 
Decortication  of  kidney,  198 

lung,  158 
Deep   infiltration,   29 


Dental  branches,  infiltration  of,  95 
nerves,  70,  75,  94,  96,   103 
by  buccal  route,  70 
by  external  route,  70 
Disarticulations,      136,     247,     250, 

254,  261,  265,  270 
Dislocations,     reduction     of,     230, 
231 
Quenu's  method  of,  230 
Dorsal  nerves,  137,   139,   144,   146, 

163 
Dorsum  of  hand,  253,  259 
Duodenum,  175 

Ear,   anesthesia   of,   85-88,   90,   91 

drum,  puncture  of,  86,  91 

external,  88,  90,  91 

middle,  86 
Elbow,  anesthesia  of,  254-256,  260, 
261 

arthrotomy  of,  261 

disarticulation  of,  261 

dislocation  of,  231 

removal    of    foreign    bodies    in, 
261 

resection  of,  261 
Empyema,    thoractomy    for,     153, 

156,  157 
Endolaryngeal  operations,  118 
Endoneural  injection,  34,  35 
Enterorrhaphy,  182 
Enterostomy,  170 
Epidural  hematoma,  43 
Ethmoidal  nerves,  81-84,   93 

sinus,  62 
Eventration,    post-operative,    188 
Excision  of  joints.  See  Resection. 
Exostosis,  88 
External   auditory  canal,   87 

cutaneous  nerve,  265-267 

saphenous  nerve,  272,  273 
Extremities,    anesthesia     of,     132, 
230.    See  also  Arm,  Fore- 
arm, etc. 


288 


INDEX. 


Eye,  anesthesia  of,  69,  91,  93 
Eye  ball,  enucleation  of,  92,  94 
Eyelids,  operations  on,  93 

Face,  anesthesia  of,  48,  97 
and    neck,    sensory    nerve    sup- 
ply of,  53 
Facial  operations,  89,  97,   101 
Femoral  arch,  198 

hernia,   195-198 
Femur,  operations  on  neck  of,  270 
osteotomy  of,  276,  277 
resection  of  condyle  of,  275 
spinal  anesthesia  in  resection  of, 
136 
Fibroids    of   uterus,    hysterectomy 

in,  168 
Fingers,    anesthesia    of,    245,    247, 
249-251,  254 
disarticulation  of,  247,  250,  254 
Fistula  in  ano,  227,  229 
intestinal,  170 
recto-vaginal,   223 
anesthesia  of,  265,  270-273 
Foot,  operations  on,  129,  265,  272, 

273 
Foramen  rotundum,  anesthesia  at, 

63,  66 
Forearm,  anesthesia  of,  260,  261 
Formulas,  anesthetic,   15 
Fracture  of  skull,  40 
Fractures,   reduction   of,   104,  230, 

232,  261,  264 
Frenum,  anesthesia  of.  217 
Frontal  nerve,  57,  60,  98 
Frontal   region,  anesthesia   of,  98 
Frontal  sinus,  62,  84 
Furuncle,    anesthesia    of,   36 
in  auditory  meatus,  88,  91 

Ganglion,  removal  of,  253,  260 
Gasserian  ganglion,  anesthesia  of, 
48,  PO 
injection  of,  50 


Gastrectomy,  163-165,  184 
Gastric     cancer.       See     Stomach, 

Cancer  of. 
ulcer.     See  Stomach,  Ulcer  of. 
Gastroenterostomy,   162,   165,   166 
Gastrostomy,   165 
Genitalia,   external,   anesthesia  of, 

200,  222 
Genito-crural  nerve,  142,  189,  190, 

202,  222 
Genito-urinary   organs,   anesthesia 

of,  132,  141,  144,  167,  168, 

197,  200,  211-224 
Gingival    branches    of    buccinator 

nerve,  96 
Glands,  removal  of,   119 
Glans  penis,   anesthesia  of,  218 
Glosso-pharyngeal    nerve,    106 
Goiter   operation,   188,   122 
Grafts,  Thiersch,  25,  263,  269 

Hallux  valgus,  operation  for,  270, 

271 
Hand,     anesthesia    of,     245,     247, 
249-255,  258,  259,  262,  263 
infiltration  of  palm  of,  246-248, 

252,  253 
phlegmon   of.     See   Phlegmon. 
Hard  palate,  anesthesia  of,  71,  72 
Harelip,  operation  for,  100 
Head  and  neck,  anesthesia  of,  48 
Heart,  operations  on,   141,  158 
Hematoma,   epidural,  43 
Hemorrhoids,  operations  for,  129, 

212,  213,  225 
Hernia,  femoral,  195-198 
inguinal,  175-188,   191,   193 
of  the  linea  alba,   186 
of  scrotum,   195 
umbilical,  186 
Herniotomy,  143,  175 
Hip,  resection  of,  265 
Hirschel's    method    of    anesthesia, 
233 


INDEX. 


289 


Humerus,  anesthesia  of,  264 

fracture  of,  232 
Hygroma     of     prepatellar     bursa, 

274,  275 
Hypogastric  anesthesia,  168 

plexus,  202 
Hypophysis,   sarcoma   of,   85 
Hypospadias,  operation  for,  218 
Hypothenar   eminence,    anesthesia 

of,  250,  252,  254 
Hysterectomy,  132,  168 
Hysteropexy,   164 

Ileocecal     region,     operations     in, 
169 
resection,  169,  170,  172 
Iliac  fossa,  operations  in,  169 
Ilio-hypogastric    nerve,     142,     189, 

190,  193 
Ilio-inguinal   nerve,   142,    189,    190, 

193,  202,  222 
Incision,   median  hypogastric,    167 

transverse  abdominal,   164 
Inferior  dental  nerve,  75,  103 
laryngeal  nerve,  117 
maxilla.     See  Jaw. 
maxillary     nerve,     57,     72,     102, 
103,  125 
Infiltration  anesthesia,    17,  21,  32, 

60,  61,  92,  115. 
Infiltration,  of  canine   fossa,  83 
of  cervical  nerve  roots,  109 
orbital,  60,  61,  92 
subconjunctival,  92 
Infraorbital  nerve,  69,  82,  83,  93 
Infratrochanteric      osteotomy      of 

femur,  276 
Ingrowing  toe-  nail,  270 
Inguinal  canal,  anesthesia  of,  216 
Inguinal  hernia,  175-188,   191,   193 
lymphatics,    operations    on,    265, 
279 
Inguino-crural    region,    anesthesia 
of,  170,  175,  189 


Injection  at  right  angles,  22 

of  nerves,  35 
Injections,  circular,  26 

endoneural,  34,  35 

perineural,  34 

pyramidal,  32 
Intercostal   nerves,    137,    139.    142, 

147,  153,  158 
Interlobar  abscess,  158,  159 
Internal  pudic  nerve,  200,  201 
Internal  saphenous  nerve,  272,  273 
Intestinal  fistula,   170 

occlusion,   128,   136 

resection,  144,  162,  179 
Intestines,  anesthesia  of,  128,  132, 
136,    141,    144,    145,    162, 
172,  179 
Intradermal  wheals,  21 
Intraorbital  injections,  61 
Intraspinal  anesthesia,   133 
Iridectomy,  93 
Ischio-rectal  fossa,  226,  227 

Jaw,  adamantoma  of,  123 

cancer  of,  104 

disarticulation   of,   104 

fracture  of,  104 

median  section  of,  102 
Jaws,  anesthesia  of,  97,  102 
Jejunostomy,  182 
Joints,  anesthesia  of,  231 
Jonnesco,  128,  132,  135 

Kidney,    anesthesia    of,    140,    141, 
144,  145,  198,  199 
operations  on,   198 

Knee,  operations  on,  129,  265,  274- 
276 

Kulenkampff's    method    of    anes- 
thesia,   234-236 

Labia,  anesthesia  of,  211 
Lachrymal  gland,  anesthesia  of,  93 
nerve,   57,  60,  98 


290 


INDEX. 


Laminectomy,  152 

Laparotomy,  165,  167 

Laryngeal   nerves,    106,    115-118 

Laryngectomy,    115,    122 

Laryngo-fissure,  118 

Laryngostomy,  118 

Laryngotomy,   115 

Larynx,  cancer  of,  122 

Le  Filliatre,  128 

Leg,  amputation  of,  265,  280,  281 

Legueu's  needle,  220 

Levator  ani,  anesthesia  of,  226  . . 

Ligation  of  external  carotid,  119, 

123,  124,   125 
thyroid  artery,  119 
Limbs,  anesthesia  of,  230 
Linea  alba,  hernia  of,   186 
Lingual  nerve,  76,  11,  79,   105 
Lipoma  of  shoulder,  264 
Lips,    anesthesia    of,    69,    99,    100, 

101 
Liver,  anesthesia  of,  132,  141,  145, 

175,  199 
Luc's  operation,  83 
Lumbar  nerves,  138,  142,  144,  146, 

150 
Lung,  abscess  of,  158 

anesthesia  of,  140,  141,  145,  158 
decortication  of,  158 
tumor  of,  158 

Malignant  tumors.     See  Tumors. 
Mammary  gland.     See  Breast. 
Mandible.     See  Jaw. 
Mastoidectomy,  90 
Mastoiditis,   operation   for,  90,  91 
Mastoid  region,  anesthesia  of,  88 
Maxillary     bones,      resection     of, 
102-104 
nerve,  inferior,  57,  72,  102,   103, 
125 
superior,  63,  65,  66,  82-84,  94 
sinus,  70,  83 
Meatus,    external   auditory,   87 


Median  hypogastric  incision,  107 

nerve,  233,  257,  258,  260 
Medius,  anesthesia  of,  247 
Mental  nerve,  79 
Mesenteric  nerves,  179 
Mesentery,   injection  of,   144,   163, 

164 
Meso-appendix,      infiltration      of, 

171,   178 
Metacarpals,    anesthesia    of,    245, 

247,  249-251,  254 
Metatarsals,    anesthesia    of,    270, 

271 
Middle  ear,  86 
Mid-frontal  region,  anesthesia  of, 

98 
Molinar,  87 

Mortality  risks  of  regional  anes- 
thesia, 1 
of  spinal  anesthesia,  134 
Moure's  operation,  82 
Mouth,  floor  of,  anesthesia  of,  105 

cancer  of  ,106,  107 
Mucous  membranes,  anesthesia  of, 

26 
Musculocutaneous  nerve,  272,  273 

Nasal    cavities,    anesthesia    of,    80 

myxoma,   removal  of,  81 

nerve,  81,  98 

polyp,  81 

septum,  resection  of,  80 

M^all,  anesthesia  of,  62 
Nasopalatine  nerve,  81 
Neck,  operations  on,  109,  119,  121 

of  bladder,   anesthesia  of,  219 

of  femur,  operations  on,  270 
Needles    for    regional    anesthesia, 

12 
Neocaine-surrenine,   14 
Nephrectomy,  129,   163,   198 
Nerve-blocking,   18,  35 
Nerves,    anesthesia    of.      See    In- 
dividual  Nerves. 


INDEX. 


291 


Nose,  anesthesia  of,  69,  80,  99 
Novocaine-adrenalin,   14 

Obstetrical  forceps,  anesthesia  for 

application  of,   213 
Obturator  nerve,  269 
Offerhaus's    measurements,   98 
Olecranon  bursa,  261 

suture  of,  261 
Ophthahnic  nerve,   57,  60,  92 

frontal  infiltration  of,  60,  92 
Ophthalmology,  anesthesia  in,  91 
Orbital   infiltration,  60,   61,  92 
Ossiculectomy,  86,  91 
Osteotomy  of   femur,  276 
Otology,  regional  anesthesia  in,  85 
Ovary,    anesthesia    of,     141,     167, 
168 

tumor  of,  167,  168 

Palate,    anesthesia    of,    54,    70-72, 
105,  108,  109 
and  tonsil,  cancer  of,  54 

Palatine  nerves,  70 

Palm     of     hand,     infiltration     of. 
See  Hand. 

Pancreas,  operation  on,  164 

Paracentesis  abdominis,  167 
thoracis,  153 

Paracostal  anesthesia,  175 

Parailiac  anesthesia,  175 

Paravertebral  anesthesia.    See  An- 
esthesia,  Paravertebral. 

Patella,  suture  of,  129,  265,  275 

Pauchet,  136,  186,  187 

Pelvic  organs,   anesthesia   of,  200 

Penis,  operations  on,  212,  217,  218 

Pericardium,   operations   on,    158 

Pericostal  anesthesia,  153 

Perineorrhaphy,   129,  223,  224 

Perineotomy,  219,  220 

Perineum,  anesthesia  of,   132,  200, 
221,  223,  224 
nerves  of,  200,  201 


Perineural  injection,  34 
Periosteum,    anesthesia    of,    30 
Periprostatic   infiltration,   220 
Peritoneum,  anesthesia  of,  143 
Petromastoid  operation,  90 
Pharyngotomy,    120 
Pharynx,  cancer  of,   107 
Phlegmons,      anesthesia      of,      36, 
253,  260 
of  forearm,  260 
of  hand,  253 
Pituitary,  sarcoma  of,  85 
Plastic  operations,  36 
Pleurae,  anesthesia  of,  143,  145, 152 
Pleural     cavity,     paracentesis     of, 

153 
Pleurotomy,  156,  157 
Pneumogastric  nerve,  106 
auricular  branch  of,  88 
Polyp  aural,  86 

nasal,  81 
Posterior    nerves,    anesthesia    of. 
See  Nerve,  Anesthesia  of. 
Post-operative   eventration,    188 
Pre-patellar    bursa,    hygroma    of, 

274,  275 
Prepuce,  incision  of,  217 
Pre-sacral     anesthesia,     202,     204, 

205,  221 
Procaine-adrenin,   14 
Prolapsus  uteri,  212,  213,  223 
Prostate,   anesthesia   of,   211,   219, 

220 
Prostatectomy,    129,   212,   220-222 
post-sacral  anesthesia  in,   222 
pre-sacral  anesthesia  in,  221 
Prostatic  adenoma,  212 
Puncture  for  ascites,  167 
of  pleural  cavity,  153 
of  tympanum  ,86,  91 
Pus-tubes,  168 
Pylorectomy,  144,  180 
Pylorus,  anesthesia  of,   145,  180 
Pyramidal  injections,  32 


292 


INDEX. 


Quadriceps     extensor,     anesthetic 

paralysis  of,  268 
Quenu's     method     of     anesthesia, 

230 
Quinine    and   urea   hydrochloride, 

17,  144,  163,  164,  167,  171, 

178,  179,  188,  226,  227,  231 

Radial  nerve,  233 
Reclus,  1,  20 

continuous  injection  of,  20 
Recto-vaginal  fistula,  223 

septum,  223 
Rectum,    anesthesia    of,    132,    163, 
200,  211,  228,  229 

cancer  of,  163,  212,  213,  229 

extirpation    of,    132,     136,    212, 
213,  228,  229 
Recurrent  laryngeal  nerve,   117 
Regional  anesthesia,  1,  17 

absence  of  danger  of  asphyxia 
in,  2 

adrenin  in,  16 

advantages  of,  1,  4 

anesthetics  for,  14,  15,  16 

armamentarium  for,  12 

asepsisi  in,  18 

disadvantages  of,  5 

duration  of,  4 

failures  in,  7 

formulas  used  in,  15 

gentleness   and  skill   in,  6 

indications   for,   11,   128,  283 

injections  in,  19,  22 

mixtures  used  in,  14 

mortality  risks  of,  1 

needles   for,   12 

novocaine-adrenalin  in,  14 

partial  anesthesia  in,  7 

post-operative    dangers    in,   2 

preparation    of    operative    field 
in,   19 

procaine  in,  16 

procaine-adrenin  in,  14 


j  Regional  anesthesia,  psychology  of 
patient  in,  9,  283 
scopolamine-morphine  before,  8, 

10 
shock  in,  2 
syringes  for,  12 
time  element  in,  9 
training  required  for,  5,  283 
unequal   adaptability  of,   10 
Regional  anesthesia  in  cranial  op- 
erations, Zl 
dental  surgery,  94 
ophthalmology,  91 
otology,  85 
rhinology,  80 
of  face  and  jaws,  97 
floor  of  mouth,  105 
ear,  85 

head  and  neck,  Zl ,  48,  109 
nasal  cavities,  80 
palate,   105 
teeth,  94 
thorax,  128 
tongue,    105 
tonsils,  105 
Resection,  ileocecal,   169,    170,   172 

submucous,  80 
Resection  of  condyles  of  femur,  275 
costal  cartilages,  155 
elbow,  261 
foot,  265 
intestine,  144 
knee,,  265 

maxillary  bones,    102-104 
metatarsals,  270,  271 
nasal  septum,  80 
omentum,  163,  188 
ribs,  143,  153,  154,  159 
Retromolar  trigone,  76,  11 
Retzius,    infiltration    of   space   of, 

213,  214,  220 
Rhinology,  anesthesia  in,  80 
Ribs,  anesthesia  of,   152,   153,  158 
resection  of.     See   Resection. 


INDEX. 


293 


Sacral  anesthesia,  202,  283 
of  genital  organs,  282 
foramina,     anesthesia     through, 

207 
plexus,  200,  201,  222 
Salpingitis,  168 
Sarcoma  of  hypophysis,  85 
Scalp,  tumor  of,  38 
Sciatic  nerve,  great,  200,  201,  269 

lesser,  269 
Scopolamine-morphine,  8,  10 
Scrotum,  anesthesia  of,   195,  214- 
216 
operations  on,  214 
Septal  nerves,  81 
Septic  buccal  cavity,  96 
Septum,  recto-vaginal,  223 
Serous  membranes,  anesthesia  of, 

143 
Shoulder,  anesthesia  of,  264 
disarticulation  of,  265 
lipoma  of,  264 
Sinus,   ethmoidal,  62 
frontal,  62,  84 
maxillary,  70,  83 
nasal,  62,  70,  83,  84,  85 
sphenoidal,  62,  85 
Skin-grafting,  25,  263,  269 

wheals,  21 
Skull  vvounds,  anesthesia  for,  40 
Space  of  Retzius,  213,  214,  220 
Spermatic     cord,     anesthesia     of, 

197,  214,  215 
Sphenoidal    sinus,    anesthesia    of, 

62,  85 
Sphincter  ani,  anesthesia  of,  226, 

227 
Spinal    anesthesia,    128,    133,    135, 
136,  265,  276 
column,  anesthesia  of,  152 
Spleen,  anesthesia  of,  140,  144 
Staphylorrhaphy,    109 
Sternum,  anesthesia  of,  143,  152,  158 
curettage  of,  143 


Stomach,  anesthesia  of,   132,    141, 
145,  163,  165,  175,  180 
cancer  of,  182 
operations  upon,  163,  180 
resection  of,   163,  164,   166 
ulcer  of,  180,  181,  184 
Subconjunctival   infiltration,   92 
Subphrenic  abscess,   158 
Superior  dental  nerve,  70 
laryngeal,  116,  118 
maxillary,   nerve,   63,  66,  82-84, 
94 
Supraclavicular    fossa,    153 
Suprapubic  cystostomy,   212,  214 
Symphysis    menti,    anesthesia    of, 

101 
Syring-es   for  regional   anesthesia, 
12 

Teeth,  anesthesia  of,  69,  70,  94-96 

Tendo  Achillis,  272 

Tendon    sheaths,    tuberculosis    of, 

253,  260 
Tenotomy  of  foot,  265 
Testicle,    anesthesia    of,    141,    197, 
214,  215 

operations  on,  214 
Thenar  eminence,  250 
Thierry  de  Martel,  46 
Thiersch    grafts,    anesthesit     for, 

25,  263,  269 
Thigh,  amputation  of,  265 

anesthesia  of  skin  of,  211 

operations    on     soft    parts     of, 
277,  278 
Thoracic  nerves,   136,   139,   144 

rigidity,   155 

walls,  anesthesia  of,   144,  153 
Thoracotomy,  143,  153,  156-158 
Thorax,    anesthesia   of,    128,    140, 

141,  143-145,  152,  153 
Thumb,  anesthesia  of,  247,  250 
Thyroid  artery,  ligation,  of,  119 
Thyroidectomy,   119,   121 


294 


INDEX. 


Tibial  nerve,  anterior,  272-274 
Toes,  anesthesia  of,  270,  271 
Toe  nail,  ingrowing,  270 
Tongue,    anesthesia    of,    79,    105- 

107,  122,  127 
Tonsillectomy,    108,    109 
Tonsils,  anesthesia  of,  105 

cancer  of,  107 
Tracheotomy,   118 
Trans-sacral   anesthesia,   203,  204, 
207,  210-212,  219,  222,  224, 
229,  283 
Transverse  abdominal  incision,  164 

colon,  operations   on,   179 
Trephining,  40,  42,  43 
Trochanter,  operations  on,  270 
Tuberculosis     of     ileo-cecal     seg- 
ment, 170 

tendon  sheaths,  253,  260 
Tuberculous  ascites,  167 
Tumors,  malignant,  36,  39,  42,  54, 
104,    106,    107,    122,    136, 
158,    161,    163,    168,    170, 
182,  212,  213 
Tumors  of  bladder,  212 

brain,  82 

breast,   160,   161 

cecum,   163 

colon,  163 

cranium,  39,  42 

dorsum,  253,  260 

forearm,  260 

hypophysis,  85 

ileocecal  segment,   170 

jaw,  104,  123 

larynx,  122 

lung,   158 

mouth,  106,  107 

nasal  cavities,  81 

neck,  119 

ovary,    167,   168 

palate,  54 

pharynx,  107 


Tumors  of  prostate,  212 

rectum,  163,  212,  213,  229 

scalp,  38 

shoulder,  264 

stomach,   182 

tongue,   106,   107,   122,   127 

tonsil,  54,   107 

uterus,  136,  168,  212 
Turbinates,   removal  of,  81 
Tympanum,  anesthesia  of,  86,  91 

Ulcer  of  stomach,  180,  181 
Ulnar    nerve,    233,    254,    256,    257, 

260 
Umbilical  hernia,   186 
Ureter,    anesthesia    of,    141,    144, 

212 
Ureteral  catheterization,  212 
Urethra,  anesthesia  of,  218,  219 

suture  of,  219 
Urethrotomy,  219 
Urocaine,  17 

Uterus,    anesthesia    of,    132,    141; 
168,  211,  214 

cancer  or  fibroids  of,  136,  168 

curettage  of,  212 

liberation  of,  223 

prolapse  of,  212,  213,  223 

Vagina,    anesthesia    of    vault    of, 
223 
vestibule  of,  222,  223 
liberation  of,  223 
Varicocele,  129 
Varicose  veins,  265,  279 
Vesical      exploration,      anesthesia 
for,  213 
operations,  212 
Vestibule,  anesthesia  of,  87 
Vulva,   operations   on,  222,  223 

Wheals,  21 

Whitehead  operation,  225,  227       ; 


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